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My research shows that the relative level of risk attributed by parents to vaccines is likely to be the defining factor in the uptake of inoculation against childhood infections such as diphtheria and polio and thus in maintaining herd immunity.

The possibility of a causal link between the measles, mumps and rubella vaccine (MMR) and inflammatory bowel disease and autism in children has received much media attention since the concern was first raised in 1998. Rigorous reviews of the scientific evidence do not support a casual link and UK health departments continue to promote MMR vaccination. However, uptake has dropped in many parts of the UK and many parents remain concerned about the safety of the vaccine. This study aimed to explore how the risk/safety of the MMR vaccine was reported in UK newspapers and discussed among parents on an Internet discussion forum. In both arenas, an impressive range of issues were discussed. These included, the quality of the available scientific literature; the status of anecdotal evidence supplied by parents; reports of increases in autism; the severity of measles, mumps, and rubella infections; the effectiveness of MMR; and single vaccines as alternatives to MMR. It was notable that while those people who doubted the safety of MMR provided specific critiques of studies that others interpreted as demonstrating MMR safety, people who supported MMR gave no such specific critiques of studies that their opponents interpreted as demonstrating an MMR-autism link. Parents expressed a range of concerns about MMR (including, the existence of scientific research that appeared to raise questions about MMR safety) and did not appear to trust the information and attempts to reassure provided by Government agencies.

This thesis investigates the process by which parents evaluate contradictory information about risk in order to make the decision whether to have their children immunised with the measles, mumps and rubella (MMR) vaccine. Contested reports associating the MMR vaccine with autism have resulted in diminished confidence and uptake of the vaccine in the UK. Interviews and focus groups were used to develop an in-depth picture of parental notions of risk, trust and decision-making processes. Cultural consensus analysis was used to probe the areas of consensus and divergence of opinion, and a large-scale postal survey (N=996) assessed the level of agreement with the qualitative findings. Parental ambivalence to the safety of the vaccine reflected wider social concerns, and was crucially related to trust in governmental medical authority and medical practitioners. Trust was particularly damaged when practitioners and policy makers failed to recognise parents' concern for their children’s health and their unique knowledge of their own children. A key tool for fostering trust is narrative: this played a central role in galvanising resistance to the vaccine, but was not well used to engender trust and cooperation between parents and medical practitioners. Three practical strategies to protect children from diseases and harmful vaccine side effects, to rebuild trust, and to cope successfully with similar controversies in the future emerged from this research: fully involving the public in framing scientific research agendas, streamlining the reporting procedures for suspected adverse reactions, and fostering trusting personal relationships between patients and health care practitioners.

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This thesis describes work undertaken to consider how strategies of vaccination can be manipulated to generate specific types and magnitude of immune response to prevent infection or treat established infection. The vaccination strategies employed were based on the initial delivery of DNA vaccine through intramuscular injection or ballistic delivery using a gene gun, followed by heterologous boosts, based on the same antigen delivered using an alternative route. These boost strategies included a) intramuscular delivery of purified recombinant HBcAg, b) mucosal delivery of HBcAg expressed by an attenuated strain of Salmonella typhimurium, and c) intranasal delivery of the protein accompanied by a mucosal adjuvant. Following each vaccination regime tested a number of specific immune responses, including serum and mucosal antibody production, CD4+ T helper proliferation in spleens and lymph nodes, CD8+ T cell activation and killing were measured. These experiments revealed that the character of the immune responses primed in response to DNA vaccination differed according to route of immunisation, with intramuscular vaccination inducing a rapid CTL response. CD4+ T cells generated appeared to be of the Th1 phenotype and showed the strongest localisation in the spleen. In contrast, following vaccination with the gene gun, CD4+ cells of a Th2 phenotype were generated with responses being found to be stronger in the local draining lymph nodes that the spleen. Combining DNA delivered using the intramuscular route with recombinant purified protein delivered by the same route was effective at boosting systemic antibody titres, as was boosting using attenuated Salmonella expressing the same antigen when delivered to the mucosal surface of the gut. In contrast, boosting of DNA primed animals with purified protein, even in the presence of an appropriate mucosal adjuvant, was not successful at increasing titres of systemic antibodies. Interestingly, specific mucosal immune responses were absent when either of the heterologous vaccination strategies used a mucosal boosting approach.

Orientadora: Drª. Liliana Müller Larocca / Dissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação Mestrado Profissional em Enfermagem. Defesa: Curitiba, 05/12/2016 / Inclui referências : f.84-88 / Área de concentração: Prática profissional de enfermagem / Linha de pesquisa: Políticas e práticas de Educação, saúde e enfermagem / Resumo: Este trabalho teve como objetivo identificar a ocorrência de perdas evitáveis de imunobilógicos notificadas no período de 2011 a 2015 em um município da 2ª RS - Metropolitana do Paraná. Com esta informação o seguinte passo, foi conhecer o processo de trabalho da Enfermagem nas atividades relacionadas à rede de frio de imunobiológicos na instância local (sala de vacina) assim como as estratégias de enfrentamento à estas perdas. Trata-se de um estudo de caso do tipo exploratório documental (fase I) com abordagem quantitativa, e de campo (fase II) com abordagem qualitativa com análise do discurso para compreensão dos dados. O município de Colombo foi identificado na base de dados por ter apresentado a maior quantidade de perdas evitáveis de imunobiológicos notificados no período estudado. Porém devido a transição dos sistemas de informação em imunização a maioria dos municípios não transmitiu a informação contendo as doses de vacinas desprezadas por causas evitáveis. Das ocorrências de perdas evitáveis de imunobiológicos a que mais se destacou foi a perda por validade vencida com mais de 87 mil doses desprezadas. Em campo, os dados foram obtidos por meio de entrevistas semiestruturadas aplicadas à 54 profissionais de enfermagem que exercem atividades na sala de vacinação, sendo que destes, nove são enfermeiros, 40 são técnicos de enfermagem e 5 são auxiliares de enfermagem. A análise do discurso foi realizada em três etapas, sendo que na primeira emergiram oito figuras: organização da sala de vacinas, aplicação de vacinas, quebra de frasco, falta de energia elétrica, procedimento inadequado, falha no equipamento de refrigeração, depredação do patrimônio, validade vencida. Na segunda elaboramos as frases temáticas que geraram duas grandes categorias: Processo de Trabalho e Perdas Evitáveis de Vacinas. A partir da categorização das frases temáticas podemos identificar que a perda de vacinas por validade vencida se sobressaiu em relação às demais, com relato de 46% dos entrevistados, e que segundo os profissionais, isto acontece devido ao fato do recebimento dos imunobiológicos ser com data de validade próxima ao vencimento, fator que não está sob responsabilidade da instância local. Sendo o profissional de Enfermagem responsável pelas ações de imunização, desde a conservação até a administração das vacinas, foi extremamente relevante conhecer de que forma a prática cotidiana da equipe de Enfermagem enfrenta as perdas evitáveis de imunobiológicos, tanto para análise do processo de trabalho, como para subsidiar os gestores da rede de frio no que tange a capacitação de pessoal em sala de vacinação. Neste caso, podemos observar que o processo de trabalho da equipe de Enfermagem nas salas de vacinas do município, pode não estar relacionado com o número de doses desprezadas por validade vencida. Concluímos que são necessários novos estudos neste domínio, uma vez que o mesmo é de responsabilidade integral da equipe de Enfermagem e há escassez de literatura a respeito de perdas vacinais, o que dificultou a discussão dos achados por meio de um amplo diálogo com o estado da arte. Palavras-chave: Enfermagem. Imunização. Rede de Frio. / Abstract: This study objectified to identify the occurrence of preventable losses of immunobiologicals reported in the period between 2011 and 2015 in a municipality from the 2nd Metropolitan Health Region of Paraná State, Brazil. With this information, the following step was to know Nursing work process on the related activities to the cold-chain for immunobiologicals at local level (vaccination room), as well as the strategies to cope with those losses. It is an exploratory documented (phase 1) case study with quantitative approach, and qualitative field approach (phase 2) by means of discourse analysis for data understanding. The municipality of Colombo, Paraná State (Brazil) was identified in the Sistema de Informação de Apuração de Imunobiológicos (Immunobiologicals Investigation Information System) database as the one with the largest amount of preventable vaccine losses reported during the studied period. However, due to the transition of vaccination information systems, most municipalities did not report information on discarded vaccination doses for preventable causes. From the occurrences of preventable immunobiological losses, expiration date of over 87 thousand doses stood out. Field data were gathered by means of semi-structured interviews applied to 54 Nursing professionals performing tasks in the vaccination room. Among those, 9 are nurses, 40 are nursing technicians and 5 are nursing assistants. Discourse analysis was held in three steps, with 8 figures emerging from the first one: organization of the vaccination room, vaccine administration, bottle break, power outage, inadequate procedure, cooling equipment failure, facility depredation, expiration date. In the second step, we elaborated thematic phrases, which generated two large categories: Work Process and Preventable Vaccine Losses. From the categorization of the thematic phrases, we can identify that vaccine losses for expiration date stood out of the others, reported by 46% of the participants, and according to the professionals, that is due to the fact that immunobiologicals are received near the expiration date, not being under local level responsibility. As Nursing professionals are held responsible for the immunization tasks, from vaccine storage to administration, it was extremely relevant to know the way that Nursing team's daily practice copes with preventable losses of vaccines, not only for the analysis of the work process, but also for grounding cold chain managers in relation to staff qualification for the vaccination room. In this case, we can observe that Nursing team's work process in the vaccination room of the municipality may not be associated with the number of discarded doses due to the expiration date. We concluded that further studies are deemed necessary in this realm, as the Nursing team is held totally responsible, and literature is scarce on vaccine losses, which made discussion of the findings difficult for scarcity of current studies. Key words: Nursing. Immunization. Cold Chain.