translation of the interview with Prof Guido Silvestri, Professor of Pathology and Laboratory Medicine
Emory University School of Medicine. Link to the original version.

"My name is Guido Silvestri and I am a specialist in Clinical Immunology, Internal Medicine, and Pathological Anatomy. I am also a researcher who deals with the topics of immunology, virology, and microbiology for over 25 years. Since 2010, I am an Ordinary Professor and Deputy Director of the Pathology Anatomy Department at Emory University, Atlanta, USA, and Director of the Microbiology and Immunology Division at Yerkes Primate Center, always at Emory University. I am the author of 220 scientific papers, which have been quoted around 17,000 times, and on 89 of these works, one of the keywords is "vaccines". I want to precise that my area of ​​expertise is the pre-clinical development of vaccines.

On the clinical and epidemiological implementation of vaccines, I currently collaborate with international experts at the Centre for Disease Control (CDC), which is the body responsible for vaccination programs here in the USA and the World Health Organization. Moreover, I have the pleasure to collaborate also with the directors of different vaccine programs for the USA, Sweden, and Finland. In particular, I would like to thank Professor Walt Orenstein, who has been Director of the USA National Vaccine Program for 10 years, Dr Ann Lindstrand, who is the head of the National Pediatric Vaccination Program in Sweden, and Dr Hanna Nohynek, Which is the head of the same program in Finland. I want to add that for several weeks I have been acting as a "consultant" on the topic of vaccines for the Five Stars Movement. During this period, I have been collaborating with Senator Elena Fattori and the European Parliamentarian Piernicola Pedicini, who are both medical and biological researchers. I want to clarify that I am not remunerated for my professional advice to the Five Stars Movement. I offer them a consultancy service that is independent of any official affiliation with this Movement.

Vaccines are pharmacological preparations developed to prevent the most important infectious diseases caused by bacteria or viruses. The important function of the vaccines is to activating and teaching to the immune system how to recognise in advance a pathogen and how to effectively combat the pathogen when enters the body. Vaccines have greatly reduced, and in one case (pox) eliminated, the incidence of serious infections, becoming the most effective measure against the damage caused by many infectious diseases. For this reason, vaccines are considered the most important medical discovery in our medical history. For example, if in a community the percentage of people vaccinated exceeds a certain threshold (usually 95%), the pathogen cannot find enough guests to become viral. This point is of particular importance in explaining the effect of the level of viruses protection for the population ("community immunity") that becomes vital for those individuals who cannot vaccinate for medical reasons (infants, children with genetic immune defects, Children who have undergone transplantation or cancer chemotherapy, etc.).
Vaccines, like all medications, are not free from contraindications and they can pose a risk to every individual who takes them. Although severe vaccine reactions are very rare (<1 / 1,000,000 for DTP, Hepatitis B, HPV, Hemophilus Influenza B, ~ 2 / 1,000,000 for anti-influenza vaccination, and ~ 4 / 1,000,000 for measles vaccination, Rubella, mumps, and varicella). The great clinical benefits of vaccination and the rarity of serious adverse reactions makes the cost-benefit ratio of vaccinations one of the most beneficial observed in medicine. It is of great importance to clarify that the hypothesis that was associating vaccines and autism was the result of a fraudulent study and it was subsequently refuted by numerous studies. Generally, the exaggeration of the contraindications of vaccines based on non-scientific considerations is a serious act of moral, social, and professional irresponsibility. This problem becomes even more disconcerting when these exaggerations come from people working in the health care sector.

We need to make extremely clear that our main objective is ensuring the highest possible coverage for those vaccines whose efficacy and safety have been scientifically demonstrated. The subsequent objective should be how to achieve this goal in the best way possible. Usually, vaccinations are implemented nationwide through so-called "national vaccination plans (or immunisations)" that differ from country to country. The strategies adopted in national plans revolve around two fundamental principles: the principle of compulsory vaccines and the principle of recommended vaccines. The choice between "compulsory" and "recommended" has complex implications and medical, scientific, social, and political ramifications. Furthermore, it is a choice that does not lend itself to hyper-simplified communication. In Italy, we hand out vaccines in a mixed mode that is based on a list of two different kinds of vaccines: compulsory and recommended. The list of compulsory vaccines handed out free of charge comprehend antidepressant, antimicrobial, antihypnotic, and viral anti-epithelial vaccine B. In the group of "recommended" vaccines, all the others kind of vaccines are included. In Europe, there are countries that prefer the "compulsory" system (France) or the "recommended" system (Scandinavian countries). In the United States, vaccinations are technically "compulsory", but there are (in 47 out of 50 states) medical and religious/philosophical exemptions, which allow parents not to vaccinate their children. In Canada, a similar approach is also adopted.

The compulsory system is, in fact, a coercive measure to ensure that families are vaccinating their children accordingly. In Italy, we introduced this system more than fifty years ago as a preventative measure that was deemed necessary by specific epidemics or endemic emergencies. The compulsory vaccination was ensuring a homogeneous, constant and timely immunisation for the whole country. The "compulsory" approach introduces procedures linking the admission to educational institutions with the vaccination certificate, thus facilitating eventual controls made by the responsible for the programming and implementation of vaccination programs. Compulsory vaccinations obviously do not involve children who have an exemption for medical reasons. It should be clear that, on one hand, the requirement for vaccination is considered a strategy to achieve the goals of the national vaccination plans; on the other hand, it is clear that many of the European programs regarding the vaccinations are effective even if they are not compulsory. In fact, for what concerns the vaccine's coverage rate, there are no significant differences between those countries using a compulsory approach and those countries that are only recommending the administration of the most important vaccinations. Actually, some countries with higher vaccine coverage, such as Sweden, do not contemplate any compulsory vaccine plans.
The idea of recommending vaccines comes from the broader concept of the "promotion of general health" that is the basis of any effective preventive action. Its aim is to encouraging families to the conscious exercise of freedom of choice, both in the interest to the health of their children and to the collective interest as well. Many studies conducted in the United States suggest that the best way to achieve high vaccines coverage is not through "punitive" measures to the families who are not vaccinating their children. Instead, the best way to achieve a high vaccines coverage is removing actively and thoroughly any "practical" obstacles to vaccination. The recommendation-based approach requires the active involvement of doctors (especially pediatricians), open and effective communication between doctors and parents, the prompt and free availability of vaccines, and if possible the use of financial incentives. Moreover, the recommendation-based approach is culturally demanding and it benefits from a cohesive social fabric. It requires knowledge on how to behave in case of a fall in the vaccine coverage rate or in the presence of epidemic outbreaks. However, the recommendation-based approach has the remarkable advantage of making feel the individual citizen part of the public health management system, which is no longer perceived as paternalistic (if not even punitive).

It is important to specify that implementing in Italy a national vaccination program based on the principle of "recommendation" it requires the adoption of four non-negotiable key points. Firstly, we need the allocation of sufficient resources to develop and maintain the necessary infrastructure required for the promotion of the recommended vaccinations and to remove any possible obstacle to the administration of vaccines. This hypothetical infrastructure includes dedicated centers in the area, medical staff, nursing staff, communication experts, free vaccine availability, computer and statistical support to monitoring the vaccine coverage over time and finally training and educational material. Obviously, this infrastructure needs to be developed and maintained at national and regional level. The second necessary key point for the functioning of a proper vaccine system based on "recommendation" is its gradual implementation at national level. This implementation will initially involve just a group of "pilot" regions, after the testing of the plan the other regions will be gradually involved in the program. This systematic implementation of the "recommendation" system will require the constant monitoring of vaccine cover rate at a local, regional, and national level. The next key point concerns the presence of a safeguard clause that contemplates the immediate reintroduction of some coercive actions, such as the possession of a vaccination certificate for admission to schools and kindergartens, if a drop in vaccine coverage rate reached a certain threshold or in the case of an epidemic outbreak. In this sense, the current measles outbreak in Italy (at least 1,600 cases in the 2017) justifies the temporary adoption of mandatory measures specifically related to the vaccine against measles. Lastly, the principle of "recommendation" should not be perceived as a default choice of "non-vaccination". On the contrary, the non-vaccination's premise should be guaranteed only to the parents who consciously make the request. The vaccines exemption should be granted only to the people that complete an educational course that includes at least two medical visits conducted in two different times, and the studying of appropriate educational material (video, film, etc.).

From a cultural and communication point of view, it must be clear that the approach based on the principle of recommendation is neither, nor can be in any way perceived, a dubious or agnostic attitude in regards to the laws defending the utility of vaccines - attitude, which, as mentioned before, is not based on scientific reasons. On the contrary, we should understand the principle of the recommendation as a social instrument to reach the highest level of vaccine coverage possible, and for the longest time possible, through a conscious an informed involvement of the population.

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