Immunization Decline: Dengvaxia effects Generalization as the Pathogen to Immunization

Apilado, Rizamari O. Arpon, Maria Mitzi C. Babalcon, James Daryl R.

Belano, Alloundra Mae L. Tabelona, Ron Isabelle D.

Vaccines are designed to protect our immune system from the occurrence of diseases such
as mumps, measles, dengue and etc. They contain either killed or weakened pathogens that once
injected generates antibodies that guards us against diseases. The pathogen contained in vaccines
is not strong enough to make an individual sick but is enough to produce antibodies to protect our
immune system once the real pathogen invades. Although, some of these vaccines can cause mild
side effects such as soreness, swelling, or redness in the place the individual is injected, and some
experience fever and rash. Severe side effects are rare that may cause life-threatening reactions or
worse, death. This is one of the major problems in immunization today because of the reported
incident of deaths of children injected with dengvaxia - “a live recombinant tetravalent dengue
vaccine developed by Sanofi Pasteur (CYD-TDV) (World Health Organization [WHO], n.d.)”. It
was the first vaccine that was licensed last December 2015 to prevent dengue caused by serotypes
1,2,3 and 4 to individuals 9 to 45 years old with prior dengue infection. This caused a drop in
compliance of getting vaccinations to 60% (Cepeda, 2018). The result broke public trust and
caused anxiety generalizing it to all other vaccines. According to the article by Hackett, Sanofi-
Pasteur admitted that Dengvaxia pose risk to those individuals who were not previously exposed
to dengue virus (Precision Vaccinations, 2018). However, despite this issue Sanofi Pasteur remains
confident with the safety of the vaccine and the World Health Organization also continue to
promote dengvaxia (Sanofi, 2018).

Background and Context

Immunization is “the process of creating immunity or protection against a particular

disease” (World Health Organization Western Pacific Region [WHO-WPRO], n.d.). The
individual is injected with a weakened virus that would trigger the immune system to produce
antibodies that would enhance its immunity once exposed to the actual disease (WebMD, n.d.).
However, even if they are designed as protection from certain diseases, they can cause side effects
just like several medications. In addition, there are cases wherein one's immune system will not
create an automatic response, and this is due to individual differences. Hence, even after
immunization, this person may still not be protected. Hypothetically, the weakened pathogen is
able to cause serious illness especially to individuals with a weak immune system. The pathogens
are able to replicate which could result to a more dangerous form of pathogen. However, the
attenuated vaccines develop a long-lasting immunity than killed pathogens because it still require
boosters to maintain the immunity in our body. This essential and egalitarian preventive health
care service is made accessible to the people even those in far-flung areas. In the country, the
Expanded Program on Immunization (EPI) was even established in 1976 through Presidential
Decree 996, and mandated by Republic Act no. 10152 “Mandatory Infants and Children Health
Immunization Act of 2011” to ensure that children and their mothers can get the vaccines advisable
for their age (Department of Health [DOH], n.d.). With the help of EPI, there will be less morbidity
and mortality rate among children.

One of these vaccines is the CYD-TDV or commonly called Dengvaxia. The vaccine is the
result of 20 years of research of Sanofi Pasteur and it was the first dengue vaccine to be licensed
last December 2015 in Mexico. This vaccine was made to boost the immune system which then
helps fight against future attacks by both viral and bacterial pathogens, or disease-causing agents.
However, Dengvaxia became controversial in the Philippines because of the 62 reported deaths
presumably caused by the said vaccine. Following this, Sanofi-Pasteur admitted that without prior
dengue infection, the individual is at greater risk in having a severe dengue which caused DOH to
stop its dengue immunization program (Aurelio,2018).

Dilemma

Immunization is essential to every individual in order to get fortified against an agent

known as immunogen. It helps people to be protected from getting an infectious disease.
Furthermore, it also helps in controlling and lessening the widespread of the disease, which helps
not only the people but the community itself. A successful immunization program depends on the
cooperation of every individual in the community (HealthLinkBC, n.d.). This program includes
vaccinations of but not limited to, polio, measles, tetanus, Hepatitis B, Rubella, diphtheria,
pertussis, pneumonia, and others (World Health Organization Western Pacific Region [WHO-
WPRO], n.d.). Many vaccines made available and offered to various communities add the benefit
by supporting the “herd community.” A herd community, also known as herd immunity, is a “form
of immunity that occurs when the vaccination of a significant portion of a population provides a
measure of protection for individuals who have not developed immunity (VaccinesToday, 2015).”

However, the immunization coverage of Filipinos are decreasing, and this is because a lot
of citizens became wary of vaccines. A huge factor that may have influenced this decrease was
because of the news on the widespread falling ill and even deaths of school-age children due to a
particular freshly-developed dengue vaccine. Last April 2016, the DOH commenced a school-
based Dengvaxia immunization program, and over 800, 000 students were administered with the
said vaccine (Cabato, 2017).

Thus, it can be assumed that the immunization decline is caused primarily by

misinformation in the cause of the effects of Dengvaxia, and the generalization of these effects on
other vaccines. There is misinformation as it can be observed that the people only assumed that
these effects were brought about just by being injected of the vaccine, when in fact these effects
happened to children who had no prior experience of Dengue. This misinformation was so deeply
ingrained that according to the examination of the public’s trust on vaccines before and after the
Dengvaxia crisis done by the Vaccine Confidence Project, there is a great change in the public’s
perception and agreement on the vaccines’ importance. It is significant in the sense that back in
2015, there was 93% of people who perceived and agreed on the importance of vaccines but this
plummeted to 32% in 2018. Furthermore, in 2015, the public’s view on the safety and effectiveness
of vaccines were both 82%, and this percentage greatly decreased to 21% and 22%, respectively,
this year (de Figueiredo, Hartigan-Go & Larson, 2018).

Imagine if a child will not get even just a single vaccine due to the fear linked with
Dengvaxia, his health will be compromised and might be put at risk for a false consensus. In the
United States last 2013, a measles outbreak transpired in Brooklyn, New York caused by one
unvaccinated teenager. According to the report, this is the largest outbreak of measles since 1992,
and before it ended, 58 were infected with measles (Thompson, 2018). Even if there were no
deaths, this is still an example of how even just one unvaccinated child can lead to several
repercussions.

Role of Scientific Advice

 The main purpose of the scientific advice is to inform and assure the people about the safety
of the vaccines being offered by DOH, as Health Undersecretary Enrique Domingo tires to
convince the public about availing “tried and tested” vaccines for their children to prevent diseases
like polio, diphtheria, measles, and tetanus. Furthermore, the agency has implemented the program
Expanded Program on Immunization (EPI) to ensure that vaccines are accessible to infants,
children and mothers. This mandates Republic Act No. 10152 “Mandatory Infants and Children
Health Immunization Act of 2011 which includes basic immunization and other types identified
by the Secretary of Health for children under 5 years of age (DOH, n.d.).

However, with the overgeneralized issue brought about by the dengvaxia incident, even
the existing policy cannot dictate the public’s compliance, unless the fear is eradicated. As Director
of the Vaccine Confidence Project, Professor Heidi Larson, have stated: “Health authorities and
immunisation programmes cannot solve political tensions, but trust issues and potential areas of
anxiety and possible dissent must be considered in advance of a pandemic.” This is also a political
issue, another factor affecting the resolution of the problem.

Some have already taken actions in resolving this particular case but, rather than alleviating
the situation, they have created more complications by pointing who is at fault and trying to gain
the public’s favor. JV Ejercito, chair of the Senate Committee on Health and Demography, has
been reported to be seeking for any irregularity in the procurement of the vaccine (Viray, 2017).
Likewise, Senator Risa Hontiveros urged the government to respond to the health threats posed by
the vaccine and believes that Sanofi should be held liable (Interaksyon, 2017). Thomas Triomphe,
Sanofi representative, was then forced to apologize during the House of Representatives hearing
on the Dengvaxia dengue vaccine.

Former Health Secretary Janette Garin said she is open for investigation which will be
conducted by the Philippine Department of Justice. The Department of Education has been closely
monitoring those students who received the vaccine since Presidential Harry Roque have reported
that 10 percent of the 733,000 schoolchildren were at risk of dengue (Malipot, 2017). On December
15, 2017, former Education and Skills Development chief Augusto Syjuco Jr filed "mass murder
and plunder" complaints against the former President Benigno Aquino III, who approved the
vaccination program during 2016, and former health secretary Janette Garin over the controversial
vaccination program (Molina, 2017). Aquino attended the hearing for the first time on February
26, 2018 claiming that the controversy has been politicized, but the Malacañang Palace denied his
allegations.

Wider Lessons and Insights

The CYD-TDV, also known as dengvaxia was released in Mexico in December 2015
(WHO, n.d.). In the Philippines, the Food and Drug Administration (FDA) approved the drug for
the prevention of disease caused by four dengue types in individuals from ages 9-45 years old
(CNN Philippines, 2018). The Philippine Department of Health (DOH), commenced the dengue
vaccination among the regions of Calabarzon, Metro Manila and Central Luzon (The Philippine
Star, 2017). However, it was suspended due to the deaths of several school children which raised
the concern that the said vaccine aggravates the potential risk to a more severe disease in some
conditions whereas the recipient had no history of dengue infection (The Guardian, 2017).

It is not only in the Philippines, but in other countries, where vaccinations numbers are
declining. In 2014, the United States saw 668 cases of measles in 23 different outbreaks-the highest
recorded number in over 25 years (Johns Hopkins Bloomberg School of Public Health, 2018).
Although vaccination rates continue to rise, so do their refusals. This decline has been attributed
to the spread of misinformation regarding the correlation between vaccines and autism. The
controversy started when Andrew Wakefield and colleagues published a paper in the journal
Lancet. Wakefield's hypothesis was that the measles, mumps and rubella (MMR) vaccine caused
a series of events that include intestinal inflammation, entrance into the bloodstream of proteins
harmful to the brain, and consequent development of autism, This paper, however, was proven to
be flawed for several reasons, and multiple studies showing that vaccines do not cause autism have
been published over the years (Children’s Hospital of Philadelphia [CHOP], 2018), however, fear
among parents still persists. Furthermore, the belief that vaccines cause autism is popular not only
among households, but also among prominent political figures. President Donald Trump has at
multiple times expressed his belief that vaccines cause autism, which may lead to the further
increase in vaccine refusals in the US.
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