By Stacy Colino
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| Vaccines Under Fire | |
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| The growing debate surrounding child immunizations. | ||
By Stacy Colino |
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"After a physician told me that Hib meningitis could cause death, paralysis,
seizures, hearing impairment, learning disorders, and more, I started feeling
angry," Walther recalls. "I was angry at my friend. I was mad at all the doctors
who were not able to answer my questions. And I was mad at myself for not
getting more reliable information before my daughter was born."
Mary Catherine remained in the hospital for 10 days, where she received
antibiotics and blood transfusions. Walther spoke with more doctors about her
concerns and conducted research in Vanderbilt's library. She finally got some of
the answers she craved. By the time their little girl left the hospital, fully
recovered and complication-free, the Walthers had decided to give her the full
schedule of vaccines. She'll be up to date by July, when she turns 2.
Fueling Fears Among Parents
Many parents are second-guessing the necessity of childhood immunizations, their
apprehension triggered largely by groups opposed to vaccines as well as by the
countless horror stories disseminated on the Internet. Although vaccination
rates have never been higher, some parents wonder whether inoculations do more
harm than good. In fact, a new survey by the National Network for Immunization
Information found that 25% of parents believe that their child's immune system
could become weakened as a result of being given too many vaccines, and 23%
think that kids get more vaccines than are good for them.
"Parents are becoming better informed about many things, and because information
is readily available in all different forms, it's helped them become more
interested in health and self-advocacy," says Bruce Gellin, M.D., M.P.H., an
assistant professor in the preventive medicine department at Vanderbilt and
executive director of NNII, a partnership formed three years ago by the AAP, the
American Nurses' Association, the Infectious Disease Society of America, and the
Pediatric Infectious Disease Society. "More parents ask more sophisticated
questions about vaccines. There's a lot of information available, but not all of
it is accurate."
Indeed, rumors about specific vaccines abound, all disputed by most doctors.
For instance, there's the belief that the hepatitis B vaccine causes SIDS, that
the DTP vaccine (for diphtheria, tetanus, and pertussis) is linked with brain
damage, that the MMR vaccine (for measles, mumps, and rubella) is linked with
autism. This last point has been rejected most recently by researchers at the
California Department of Health Services, who found no correlation between the
increased rates of vaccination and autism.
Factor in the notion that immunizations in general can be blamed for the rise in
childhood asthma, diabetes, and other chronic diseases, and it's no wonder that
growing skepticism about vaccines has many physicians worried. The childhood
immunization program is considered one of the greatest medical successes of the
20th century. "We've taken diseases that routinely killed or harmed children and
either completely or virtually eliminated them," says Paul Offit, M.D., chief of
infectious diseases at Children's Hospital of Philadelphia and coauthor of
Vaccines: What Every Parent Should Know.
A Medical Mission
Pediatricians are concerned that fears about vaccine safety will further erode
support for immunization, result in a decreased vaccination rate, and,
ultimately, lead to outbreaks of these diseases. "The antivaccine groups keep
putting out literature and showing up on television, claiming that vaccines are
dangerous. We have decades of data showing that vaccines are safe and effective,
but physicians haven't been as good about getting the word out about the
benefits," says David Greenberg, M.D., an associate professor of pediatrics at
the University of Pittsburgh School of Medicine.
Among the sticking points in many parents' minds are those frightening
stories of outcomes supposedly associated with a particular vaccination. Experts
say there is no scientific basis for most of their worries. In fact, they say,
parents' concerns about vaccines stem in part from the very success of the
vaccine program. "These diseases are totally unfamiliar to today's parents, as
well as to younger healthcare providers, so instead of being concerned about the
diseases, they shift their focus to the vaccines," explains Dr. Gellin. "Because
the diseases are essentially unknown, the vaccines are not fully understood."
And that is where the medical community comes in, joining together to create a
dialogue based on reliable vaccine information. "NNII was formed because the
voice of the physician seemed to be lost in this discussion," says Dr. Gellin.
"We want to create a partnership between healthcare providers and parents on
this issue." A similar organization was launched earlier this year: National
Partnership for Immunization (NPI,
www.partnersforimmunization.org), funded in part by the Centers for Disease
Control and Prevention in Atlanta. NPI's mission is to encourage greater
acceptance and use of immunizations.
What some parents may not know is how susceptible children are to even rare
diseases. "None of them is more than a plane ride away," says Samuel Katz, M.D.,
professor and chairman emeritus of the department of pediatrics at Duke
University School of Medicine in Durham, NC. For example, "there's polio in
Africa and diphtheria in the former Soviet Union." When these outbreaks occur
around the globe, the diseases can easily be imported to the U.S.
Even here, many of the viruses or bacteria that cause diseases like whooping
cough (pertussis) are still circulating. "Vaccines are so critically important
because if 10% to 15% of the population don't get immunized, then the diseases
return and cause outbreaks," says Dr. Greenberg.
Indeed, in a recent study led by the CDC, researchers investigated the risks
of measles and pertussis among kids ages 3 to 18 in Colorado from 1987 to 1998
and found that those whose parents chose not to immunize them were 22 times more
likely to contract measles and six times more likely to get pertussis than
vaccinated kids. Among young children, who are especially vulnerable to these
diseases, unvaccinated kids in daycare and primary school were 62 times more
likely to get measles and 16 times more likely to develop pertussis than those
who'd received their shots. Meanwhile, in the United Kingdom, some parents have
brought their children to "measles parties," with the goal of exposing them to
measles so they wouldn't have to receive the vaccine, says Dr. Gellin. What's
happened is that vaccine rates for measles in the U.K. have decreased and
there's been a resurgence of cases and an increase in deaths from the disease,
says Cody Meissner, M.D., chief of the pediatric infectious disease service at
the New England Medical Center in Boston. "It's quite tragic."
Selective Vaccination
In some cases, parents won't think twice about having their children immunized
against serious diseases such as diphtheria, tetanus, polio, and measles, but
they will question the necessity of others. Johanna Cowie, 39, of Sandy Spring,
MD, decided against giving her son Max, now 5, the varicella (chicken pox)
vaccine because she felt that the vaccine was more of an unknown than the
disease is. "I tend to believe in vaccines, but I wanted to wait with this one
since it hasn't been around that long," she explains. "Besides, I had chicken
pox as a kid, and I don't remember it being that horrible. I figure if Max
doesn't get chicken pox by the time he's 10 or 12, he could get the vaccine then
and it would carry him through adolescence, when chicken pox becomes more of a
problem. My pediatrician thought that seemed quite reasonable."
Selectively vaccinating a child gets mixed reactions from pediatricians. "I
see kids who have very serious consequences of varicella, and many parents
falsely think that chicken pox is a mild disease," says Neal Halsey, M.D.,
director of the Institute for Vaccine Safety at Johns Hopkins University in
Baltimore. "It can be, but it can also be a serious disease with potentially
life-threatening complications, and we can't predict who will have them. But we
do know that the risk of developing complications from chicken pox is 1,000
times greater than the risk of having a bad reaction to the vaccine," he says.
Nevertheless, some pediatricians, like Cowie's, are perfectly comfortable with a
child's forgoing the newer varicella or pneumococcal vaccines even though they
are recommended by the AAP. Many doctors are less understanding, however, about
a parent's desire to skip the older, well-established vaccines -- or to keep a
child from receiving all doses of a particular vaccine. "The last thing you want
is for a child to get two doses of a four-dose series," Dr. Gellin says,
"because that means she isn't adequately protected."
While some parents resent state mandates that require them to vaccinate their
kids before entering daycare or school, it's a matter of balancing individual
rights against the greater good, says Kathryn M. Edwards, M.D., professor of
pediatrics at Vanderbilt University. "What if not immunizing your child exposes
another child to a disease that could be serious? We can assume risks for our
own children, but I don't think it's fair to assume risks for other children.
That becomes a much harder public health issue."
In some instances, doctors do support withholding certain live vaccines -- such
as MMR and varicella -- from children who are immunocompromised (because they
have leukemia, for example). "And in rare cases, children develop a serious
reaction to the first vaccine dose and can't get subsequent ones," says Dr.
Halsey. Exemptions for medical reasons are allowed in all states. In 48 states,
parents can withhold vaccines for religious reasons; 17 states permit
philosophical exemptions, according to the Albert B. Sabin Vaccine Institute in
Washington, DC. For a religious exemption, some states require a signed
statement from parents, while others require one from a clergy member, notes
John Clymer, the institute's vice president of external affairs. For
philosophical exemptions, parents generally must file a letter with the school
system, explaining why vaccines are against their beliefs.
And if physicians and parents don't see eye to eye? Sometimes they're at an
impasse. Take the rotavirus vaccine as a case in point: The vaccine went through
the proper testing and approval process, was found to be safe based on the data,
and was approved. Only when it was used in a larger sample of children were rare
complications found, which is when it was pulled from the market. While doctors
see this as a reassuring example of how the system works, parents don't. In
fact, this debacle often fuels parents' fears of what might be discovered in the
future about other vaccines.
Education Efforts
So how much should doctors try to persuade reluctant parents to vaccinate their
kids? Some pediatricians say that sometimes the only choice is to agree to
disagree. "We should talk to parents and give them responsible information,"
says Dr. Offit. "If they're still uncomfortable vaccinating, then so be it.
Physicians have to be willing to play it the parents' way for a while. They
shouldn't dismiss those patients from their practice. When you dismiss them,
they're gone and you have no chance of vaccinating their child."
Doctors hope that the immunization rate will continue to rise despite some
parents' suspicions. In the meantime, researchers are developing new delivery
systems -- such as nasal sprays and edible vaccines -- and new combinations of
injectable vaccines, which will likely mean fewer needle-sticks for kids. Only
time will tell whether that will be enough to allay all the concerns, but for
now, more and more physicians are prepared to address parents' worries. They're
coming together through forums like the NNII and NPI to brainstorm and update
parents on the latest research. They're arming themselves with facts. And
they're ready to refer parents to reputable sources of additional information.
In fact, in a recent survey of AAP members, 76% of doctors reported that within
the previous three months, no parents had brought an immunization issue to them
that they couldn't adequately address. "All we can do as healthcare providers is
try to educate parents about these vaccines, reassure them about their safety,
and remind them that the diseases we're trying to protect their children against
are very serious,"says Dr. Greenberg. This way, parents will be able to make
better-informed decisions -- which is precisely what doctors want too.
Which Vaccines Does Your Child Need, and When?
Here's this year's recommended immunization schedule, from the American Academy
of Pediatrics:
Hepatitis B
Dose 1: Between 0 and 2 months
Dose 2: Between 1 and 4 months
Dose 3: Between 6 and 18 months
Diphtheria, Tetanus, Pertussis (DTP)
Dose 1: 2 months
Dose 2: 4 months
Dose 3: 6 months
Dose 4: Between 15 and18 months
Dose 5: Between 4 and 6 years
H. influenzae type B (Hib)
Dose 1: 2 months
Dose 2: 4 months
Dose 3: 6 months
Dose 4: Between 12 and 15 months
Inactivated Polio (IPV)
Dose 1: 2 months
Dose 2: 4 months
Dose 3: Between 6 and 18 months
Dose 4: Between 4 and 6 years
Pneumococcal Conjugate
Dose 1: 2 months
Dose 2: 4 months
Dose 3: 6 months
Dose 4: Between 12 and 15 months
Measles, Mumps, Rubella (MMR)
Dose 1: Between 12 and 15 months
Dose 2: Between 4 and 6 years
Varicella
Dose 1: Between 12 and 18 months
Dose 2: Between 11 and 12 years
Copyright © 2001. Reprinted with permission from the
June/July 2001 issue of Child Magazine.
ALL INFORMATION, DATA, AND
MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION
PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS
OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR
LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND
COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH
YOUR HEALTH CARE PROVIDER.
