Editorial article
Vaccinal calendar
Calendario vacunal
Carlos Rodrigo Gonzalo de Liria
Servicio de Pediatría, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Barcelona, Spain
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It is the product of a logical, reasoned, scientific and attainable selection and, to a larger or shorter extent, positive and permissible of the diseases we want to prevent, the age we consider suitable to initiate and to follow the immunisation, the interval between doses, the guidelines of administration and, even, the commercial pharmaceutical preparations that we consider to be preferable to use.</p><p id="par0015" class="elsevierStylePara elsevierViewall">It seems to be easy, right? But it is absolutely not. In fact, the selection of the vaccines and the administration that will be part of the vaccination schedule is one of the most complex processes that health authorities, who have the political, social and economic responsibility of implementing it and do it successfully, have to face.</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is so complicated, and needs of so much theoretical and practical considerations, that none of the autonomous communities of Spain–each with their own competency in public health issues–has agreed with one another when establishing a vaccination schedule.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,4</span></a> And the same can be said about the enormous diversity of vaccination schedules that exist among the countries in the European Union (EU). These facts make it clear that this is not a simple task, and that the existence of divergences has well-sounded explanations. It may be susceptible of pressure, demagogy, interested discussions, personal, group or collective opinions. Some of them may be reasonable, some justified, some are “based on the evidence”, some may be indicative, and some others… In any case, it is necessary to recognize that it is possible to reach similar results of success with different strategies, and that only by constructing it in conjunction with all the involved parties a unique vaccination schedule could be attainable.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Is it a good thing that there is such a disparity of immunisation schedules in the same country and in the same WHO region (Europe)? No, by all means. Is it bad? No, neither it is. Although it is truth that it would be more comfortable and easier to understand for everybody. It is as real as real life. The vaccines and, consequently, the vaccination schedules are not alien to the context, the characteristics, the changes, the discussions, the detractors and the obstinate defenders that affect our lives and our society. It is consequence of the conditions and peculiarities of the society in which we live: the Western society, substantially selfish, developed and wealthy compared with other densely populated societies, with a political system based on regular democratic elections and essentially with liberal economies. Always with the well-being as the non-negotiable objective. With variable and diverse social policies. With undeniable demagogic and showy ingredients. With alternating and coexisting fears and arrogance. Often capricious and incongruous, it demands perfect performances from public authorities and health technologies, without easily accepting the risks and the collective commitments.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The vaccines, the most unquestionable effective and efficient measurement for survival and health of the global population, after the issue of water purification–which not for being a well-worn phrase or for having the appearance of a topic is less true and needs to be remembered, because it often appears to be forgotten–are denigrated from tribunes and from all kinds of scenarios, some of them really surprising. There are opposite voices coming from the health community; from people with a grate charisma and media appeal, although nothing in fact makes presume authentic knowledge of the matter; from the politicians of all the political spectrum, although not a minimum knowledge is expected from them, even when they have some sanitary degree; from those affected, independently of the causal or accidental relation of the vaccine in that affectation.</p><p id="par0035" class="elsevierStylePara elsevierViewall">About the latter group, they deserve a special respect and some considerations. Respect towards those who have suffered from a negative reaction to vaccines and respect for those who have suffered a disease that could have been prevented with an immunisation that was never administered. Both should receive a special socio-health care attention and all the public support they require.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">7,8</span></a> But they cannot be the ones who dictate the performances on the vaccination issues because they are not even impartial. They cannot be impartial because they are necessarily slanted for personal reasons, for their suffering, some because they have received the vaccine and the others because they have not. In this respect, the situation regarding the polio vaccine is very relevant: some people appeared after 50 years of feeling aggrieved because they consider the delay in the decision to vaccinate against polio in Spain is the cause of their disease and severe sequels, and demands are presented from victims of the attenuated virus oral vaccine–a vaccine that, due to the low cost and the ease administration, has done so much for the elimination of polio from the planet–who suffered a paralytic illness caused by the presence of the virus in the vaccine.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Everything in this life has benefits and risks. What happens is that regarding the vaccines, for those vaccines being commercialized at present, the expected benefits completely exceeds, scientifically proven with real data, any potential risk.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9,10</span></a> Risks that exist and that cannot be denied or omitted. Risks that deserve a very rigorous attention in accordance with what a serious, conscious and developed society with human and ethical values must do to adequately compensate the very few–and I emphasize very few–citizens that by idiosyncratic reasons most of the times (and, therefore, neither presumable nor avoidable) have badly suffered from bad outcomes as a result of providing good outcomes to the majority of the citizens.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> It is an undesirable effect that we know happens in a very tiny percentage of the occasions, but that happens, and that should be acknowledged to avoid losing credibility.</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is evident that a vaccination schedule is needed so that all the children of a certain territory can be vaccinated with the vaccines considered to be appropriate, and that they have to be administered at defined ages with the objective of optimizing the moment of immunisation, ensuring the vaccination coverage by means of facilitating their implementation.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> However, this schedules do not need to be identical in all the adjacent territories. And here we have a relevant aspect: Is it necessary that the neighbouring countries have the same schedule or that the different autonomous communities from a same country have a unique vaccination schedule, adjacent of not? There must be an agreement on what vaccines must be included in the vaccination schedule for the population in that specific territory, from a conceptual point of view. I would dare say it has to be a medical point of view with all the implications of the term: which implies the health, scientific, human and social aspect, although the agreement has not to be complete. In fact, it is a decision that has to follow health policies that has to be established following those coordinates, avoiding those coming from the emotional opinions, the informal meetings or the purely scientific coordinates. This is a higher-level. Of course it requires precision and objectivity, both characteristics of the scientific methods, but in the lands of uncertainty or cost of opportunity it is necessary to apply criteria that combine the public health with the social and economic welfare and the sustainability of the health system.</p><p id="par0050" class="elsevierStylePara elsevierViewall">And here we have a new concept that I consider to be crucial: the value–in its philosophical sense–of vaccines. Some realities have the quality of being considered as goods, quality that makes them valuable and therefore, desirable; and, as the Royal Spanish Academy (Real Academia Española) dictionary defines it, values can be positive or negative and are hierarchically positioned in superior or inferior places.</p><p id="par0055" class="elsevierStylePara elsevierViewall">There is no doubt that vaccines are considered to be a positive value positioned in a superior place of the hierarchy. In standard conditions (without a disease or differential epidemiological predisposition) efforts should be made to get all the children from a specific territory vaccinated according to the official vaccination schedule for that specific territory–regardless of the extension and limits–or at least to give them the real possibility of being offered to receive the vaccines (we have to remember that vaccination is not mandatory in Spain), all the vaccines and exactly the same vaccinations. It has to be soundly decided, with the utmost medical thoroughness and health and social justice, what vaccines will be included in the vaccination schedule and then ensure supply with adequate domestic financing. The enormous value of vaccines is lost when it becomes a discriminatory issue, when vaccines have to be bought with private money, which results in children not being vaccinated due to lack of money. It is necessary to protect, in addition, the great value of vaccines, by itself, from the really dangerous–for the health of the population–anti-vaccine movements.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">We are living a high-risk situation that reminds me of that proverb about people washing their hands off the matter (“all contributed to kill her, but she died alone”), since there are too many actors involved–many of them with authentic good will and the majority with acceptable reasons, but with no community perspective–whom in the end are contributing to the underestimation and the loss of prestige of vaccines.</p><p id="par0065" class="elsevierStylePara elsevierViewall">It is not possible to give insufficient or incorrect justifications to explain the withdrawing of a vaccine that has been used for years. We do not have to support risks or benefits without the adequate verification. We cannot recommend parents to buy for their child a vaccine that they cannot afford.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All the vaccination schedules in the 17 autonomous communities and the 2 autonomous cities in Spain are excellent. The differences among them are not significant and they correspond, exclusively, to the freedom of decision and to the autonomy those territories have to decide in public health matters. All of them guarantee an adequate protection and a universal and free access to vaccines against diphtheria, tetanus, whooping cough, infections caused by <span class="elsevierStyleItalic">Haemophilus influenzae</span> type b, hepatitis B, meningococcal C vaccine, measles, rubella, mumps, chickenpox in teens of both sexes before arriving at the adult age and HPV for teen girls. They are made following the primo-vaccination guidelines and booster doses absolutely verified and validated within their small differences.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,4</span></a> In addition, some communities and autonomous cities have included other vaccines that have been considered appropriated by their advisory boards or committees and whose local health systems have agreed to finance, prioritizing this cost over other interests and necessities: hepatitis A, in Melilla, Ceuta and Catalonia; chickenpox for children in Navarre, pneumococcal vaccine in Galicia; whooping cough to protect pregnant women and infants of 4 months of age in Catalonia.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">This is not inequality that an autonomous community, with different budgets and different political priorities in education, culture, social welfare, health, protection of citizens, etcetera, has some vaccines included in the vaccination schedule that other communities do not have. Those are different options taken free and legitimately; we do not have to demand egalitarianism when the fundamental conditions are guaranteed, namely, the vaccines the Health Departments considered to be essential and relevant. The inequality starts when we leave to the hazard of the money, being able to pay or not, something as important, as valuable, as deserving of our defence and protection as the vaccines we give our children and teens.</p><p id="par0080" class="elsevierStylePara elsevierViewall">What is the situation of the countries in our economic, social and epidemiological environment? It is not very different from what happens in Spain, with the diversities decided by their health authorities. Let us see a few prime examples within the EU (28 countries).<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">15,16</span></a> Only 8 countries recommend the chickenpox vaccine, out of which Austria (does not finance it), Germany, Cyprus, Greece, Latvia and Luxembourg vaccinate in the second year of life; the other 2 are Spain and Italy, who recommend it and exclusively finance it in the pre-teens without history of having had the disease or who have not been vaccinated yet. Seven countries vaccinate against rotavirus and 19 gives pneumococcal vaccine.</p><p id="par0085" class="elsevierStylePara elsevierViewall">There are 3 countries (Denmark, United Kingdom and Sweden) that only vaccinates with hepatitis B to the children of mothers infected with that disease. Only 4 countries, including Spain, give meningococcal C vaccine during the first year of life; other 9 vaccinate with a single dose between 12 and 15 months of life.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Only Greece–the country with the most complete vaccination schedule in the EU–vaccinates against hepatitis A in the second year of life. Austria, as it does with other vaccines, recommends it but does not finance it. The Czech Republic administers it in the adult age (from 18 years of age).</p><p id="par0095" class="elsevierStylePara elsevierViewall">It is very surprising and peculiar what happens with the vaccination against encephalitis transmitted by mites, a disease characteristic of few Central European countries. While Austria applies a regular and systematic schedule of immunisation from the first months of life, with a booster dose every 5 years up to age 60 and every 3 years thereafter; Germany does not even considers it; the Czech Republic administers it in adults and Finland limits it to the inhabitants of the Aland island, and reserves it to children older than 3 years of age.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The HPV vaccine, condemned by the Spanish anti-vaccination groups, is recommended in all pre-teen girls in 20 countries of the EU, that is to say, it is one of the vaccines that has built greater consensus and interest.</p><p id="par0105" class="elsevierStylePara elsevierViewall">All the countries systematically vaccinate against whooping cough, tetanus, polio, <span class="elsevierStyleItalic">Haemophilus influenzae</span> type b, measles, rubella and mumps.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Flu vaccine for children between the age of 2 and 4 is given in 6 countries (Finland, Malta, Slovakia, Slovenia and United Kingdom; Austria, as in other occasions, recommends it but does not pay for it). The United Kingdom is the only country that uses the intranasal vaccine with live attenuated viruses.</p><p id="par0115" class="elsevierStylePara elsevierViewall">These conspicuous differences in the vaccination schedules among the EU countries, which are to be trusted in their capacity of making the right decisions regarding public health issues, reveal the difficulty to build consensus between the people in charge, the experts in prevention of infectious diseases and the health authorities of each country, region and community. With the scarce exceptions of the infections at the local level, the rest of the immunisations that I have mentioned are potentially applicable to all the children in all the countries.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> Certainly, the reasons why some vaccines are not included in the vaccination schedule are not related to the security and efficacy of the vaccines,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> but rather, to the criteria of health policies, which include other concepts such as the opportunity cost, and other values such as the prioritizing of expenditures to optimize resources and the support of the citizen needs in a fair way.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Those who consider that vaccines in general, and all the vaccines mentioned in this article, are a priority, have the moral duty to explain and to soundly justify, comparing with other health measures, the importance of immunisation.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">19,20</span></a> We have to do it by convincing all the stakeholders involved in the health decision-making about the benefits for the population of having a vaccination schedule as large as possible and, of course, free of charge for everybody who needs it.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> Only the vaccines funded by the governments–national or autonomous – or by the social organizations created to cover the needs the governments do not cover, are really valuable and valid in a society with the ethical culture of well-being.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the meantime, we have to be satisfied with the vaccination schedule we agreed on through the committees and the vaccination advisory boards and that we have for each autonomous community–legally responsible for the public health of its citizens. We must avoid confrontations between the scientific associations and the administrations, who are very well-meant but do not contribute with real value. The efforts have to be focused on persuading and demonstrating irrefutably that we are right. It is clear that to achieve this, the public administrations must listen and allow the participation in the decision making of the health professionals that have contributed the most in the success of the universal vaccination in Spain: the paediatricians. They are the real authors of the general acceptance in parents to immunize their children. They have been working along with the technicians in the vaccination programmes that make vaccines available and with the nurses that administer them. Paediatricians are responsible therefore for the excellent vaccination coverage reached and maintained for years in our country.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> This way, it would be much more easy to build agreements and to ensure a general commitment for the sake of vaccines, the children and, ultimately, for the sake of society.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodrigo Gonzalo de Liria C. Calendario vacunal. 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