Minnesota Medicine

Published monthly by the Minnesota Medical Association
February 2002/Volume 85

No Shots for My Child!

With effective responses and resources, physicians can reassure parents who question the safety of vaccines. 

By Jodi Ohlsen Read

Handing the infant back to her mother, you jot down a few notes in the chart and turn to the mother. “Today we’ll be giving her DTaP, Hib, and polio immunizations,” you say, ready to give the mother the required Vaccine Information Statements. 

“Actually, I don’t think we want to do that,” says the mother, handing you some printouts listing the dangers of vaccines. “We believe vaccines compromise the natural immune system. And, the risk of side effects is just too high.”

A touchy, often frustrating situation for physicians, scenarios like this are not that uncommon. Although U.S. immunization rates are at an all-time high, parents are increasingly concerned about vaccines. Many have misconceptions about the way vaccines work and the associated risks. The 1998 withdrawal of the rotavirus vaccine because of a suspected connection to rare cases of intestinal blockage in children, media coverage of the mercury-containing thimerosal preservative in vaccines, and stories about other supposed links between vaccines and disease have spawned even more unease.

Parents are looking for answers. Fortunately, most still consider their physician the primary source of reliable medical information. It does take time to explain the details of immunization policy, vaccine manufacturing, and risk assessment. But brief or extensive, the physician’s response to parent’s questions and opinions is crucial to preventing declines in immunization rates. Often parents simply need more facts to feel secure about the substances being given to their children. 

“My first responsibility is to be an educator, to be sure the families have as much knowledge as possible,” says Sally Kline, M.D., a family physician at Eden Prairie Clinic. “Most of the barriers people have about vaccinations stem from misinformation that frightens them. Generally, more accurate information helps.”

There is an abundance of material about vaccine safety on the Internet. The Centers for Disease Control and Prevention (CDC), World Health Organization, the Food and Drug Administration (FDA), and other organizations offer a wealth of science-based information (see resource list on p. 27). However, there is also plenty of unsound antivaccine information, which may appear to be legitimate and rooted in science. This information is put out by antivaccine groups such as the National Vaccine Information Center (NVIC), which was founded in 1982. While the NVIC advocates scientific research in vaccine safety, it also puts forth numerous antivaccine theories. The information the group presents to the public can confuse and mislead parents.

Reactions and Risks

Antivaccine materials emphasize the risks of immunizations. Vaccines are not without risk, and researchers are continually seeking ways to make them safer and more effective. The existence of this ongoing research is enough to cause some parents to question the wisdom of vaccinating their children. One adverse reaction out of 10,000 may not be statistically significant—but it may seem to be one reaction too many to parents worried about it occurring in their child.

Simply explaining the vaccine’s benefits along with its risks helps put things into perspective for many parents. Without firsthand experience with a disease, parents may have a hard time imagining the devastating possibilities of polio, whooping cough, Haemophilus influenzae type b (Hib), or tetanus. Discussing and expanding on the Vaccine Information Statements that physicians are required to give to patients before administering any vaccine may also be reassuring. 

Often horror stories about adverse reactions may involve older versions of the vaccines that are no longer used. Vaccines are safer than they have ever been before, says Kline. For example, in 1997, safety concerns about the whole-cell pertussis component of the diphtheria tetanus pertussis vaccine (DTP) prompted a change to the DTaP, which includes the purified, acellular pertussis vaccine and is much less likely to cause mild to moderate reactions such as fever and seizures. 

Parents may also be concerned about preservatives in vaccines—thimerosal in particular. Preservatives have been added to vaccines for more than 70 years to prevent bacterial or fungal growth. In some vaccines, substances called stabilizers are used to help the vaccine remain effective. All parts of the vaccine are tested by the FDA for safety, purity, and potency.

Concern about thimerosal stems from the fact that it is a derivative of ethyl mercury, which has been thought to cause neurological damage. Although no child was shown to be harmed by thimerosal in vaccines, the FDA has changed the requirements to reduce or eliminate thimerosal from hepatitis B, Hib, and DTaP vaccines. Since October 2001, the majority of DTaP, Hib, and hepatitis vaccines have been thimerosal-free or only contain trace amounts of the preservative.

Many Misconceptions

One common belief among those opposed to vaccines is that multiple immunizations compromise the immune system. Parents may be especially concerned when a child receives up to five vaccinations at one time. They need to be reassured that infants and children are exposed to many, many germs every day and their bodies are able to handle those assaults; the vaccines given during the first year are a negligible load on the immune system compared to the daily onslaught of bacteria. Parents need to understand that vaccinations help strengthen the immune system by protecting the child from the actual disease, which would be much more taxing than the vaccine. They also could be told that if the child were to contract the natural disease, his immune system would be compromised, making it harder for him to fight off a second infection such as pneumonia.

Some people have concluded that vaccines are no longer necessary—that diseases have been reduced or eliminated because of improved hygiene, sanitation, and nutrition rather than vaccines. It’s true that improved conditions have had an impact on disease and survival rates, but the number of people who contract disease has been most directly affected by vaccines. For example, a 1999 study published in JAMA showed that a dramatic, permanent drop in the number of measles cases coincided with the introduction of the vaccine.1 Also, countries in which immunization levels have dropped have experienced epidemics of pertussis. According to the CDC, these experiences show us that such diseases would come back if we were to stop vaccinating.

The success of immunizations—manifested in the decrease in or elimination of many diseases—may contribute to a lax attitude about vaccinating. Parents need to be reminded that although they do not see diseases such as polio, measles, or pertussis often in the United States, these diseases are still prevalent in other parts of the world. Travelers can unknowingly carry these diseases, and epidemics would spread through a nonvaccinated population.

Parents need to understand that complete immunization is essential to protect everyone. They may not realize that not immunizing their child not only jeopardizes their child’s health but also the health of others. 

“I have a societal responsibility to promote vaccinations,” says Kline. Because vaccines are not 100 percent effective, some children are not fully immunized, and those children are at risk, she explains. “They need to be protected also by having as much of the community vaccinated as possible.”
Antivaccine literature widely perpetuates the idea that the people most likely to get diseases such as polio, measles, and pertussis are those who have been immunized for those diseases. This concept is simply a manipulation of statistics. Since no vaccine is 100 percent effective, a number of vaccinated individuals will become infected during an outbreak of measles, for example. And, because the majority of people in the United States have been vaccinated, the odds are that more vaccinated people than nonvaccinated people will become infected.

Reasoning and Research

There have been many claims that vaccines may be responsible for diseases that are unrelated to the infectious agents that vaccines protect against. The fears are many: that the MMR vaccine causes autism; that the Hib vaccine causes diabetes, that the DTP vaccine is associated with sudden infant death syndrome (SIDS), and that the hepatitis B vaccine is responsible for cases of SIDS and multiple sclerosis.

Some of these misconceptions have stemmed from the attention the media has paid to single research studies, as is the case with reports of the MMR-autism link. A study with a sample size of 12 associated the MMR vaccine with an inflammation of the intestines that preceded autism. That study received substantial media coverage; however, a subsequent study with a more rigorous design and 500 subjects that disproved the link was not as widely reported. Anecdotal accounts reported in the media can also contribute to public misconceptions. For example, the purported link between hepatitis B and SIDS, for which there is no evidence, has been bolstered by a TV news magazine account of a child who died of SIDS within 16 hours of receiving her second dose of the vaccine. 

In other cases, such as in diabetes and asthma, the introduction of a vaccine or an increase in immunizations has occurred over the same time period in which the incidence of the disease has risen; but no causal effect has been proven. A similar situation in which correlation and causation are confused is the perceived link between SIDS and the DTaP vaccine—most SIDs deaths occur during the age range when children receive the doses of the vaccine.

Parents need help in understanding the scientific research process and should be made aware that they need to look beyond single research studies and anecdotal accounts in the media. Helping them understand the role of such bodies as the American Academy of Pediatrics, the American Association of Family Physicians, and the CDC in evaluating the body of scientific evidence regarding vaccine safety and pointing parents to Web sites with accurate information could go a long way in addressing their concerns. The resource list on p. 27 contains many useful Web sites, and the two-page handout for parents, “The Facts about Childhood Vaccines,” reprinted on pp. 29-30, is available in pads of tear sheets free to providers from the Vaccine Education Center of Children’s Hospital of Philadelphia.

It is important to note that parents do have the option of a legal exemption from the Minnesota law requiring students to be immunized before they can attend school. A notarized exemption form (available through schools or the Minnesota Department of Health) or letter must state the request for exemption for medical reasons or conscientiously held beliefs. Beginning this year, this option for legal exemption must be presented to the patient at the same time as the requirements are presented, in the same style and in the same size font. Federal law already requires that Vaccine Information Statements listing the benefits and risks of immunizations be handed out before each dose is administered.

Often parents may only need basic information or want to be reassured about a particular aspect of a vaccine. Others will require more complete material and may continue to refuse vaccinations. When dealing with those parents who will not vaccinate their child, continuing to offer facts about the benefits and risks of immunizations at each visit in a respectful, nonconfrontational style is useful, recommends Kline.

When deciding how to respond to a patient’s question, it is important to look at the reasons patients are asking, says Kline. “It’s not that they don’t trust us as physicians. They are simply fulfilling their most important role as advocates for their children.” 

The information in this article has been compiled from the Web sites of the Centers for Disease Control and Prevention, the World Health Organization, and the American Medical Association unless otherwise noted.

Jodi Ohlsen Read is a freelance writer living in Nerstrand.

Reference 

1. Centers for Disease Control and Prevention. Epidemiology of measles—United States, 1998. JAMA. 1999;282(14):1323-44.

Vaccine Resources for Physicians and Their Patients

General Resources

Immunization Action Coalition
www.immunize.org

Provides a wealth of up-to-date vaccine information for health care providers and their patients, including materials in 27 languages, ordering information for a video on immunization techniques, and the opportunity to sign up for electronic and print newsletters.

National Immunization Program, Centers for Disease Control and Prevention 
www.cdc.gov/nip

Includes information about vaccine safety, reports and statistics about vaccine coverage, and many other resources.

Vaccine Education Center at the Children’s Hospital of Philadelphia
http://vaccine.chop.edu/

Includes “The Facts About Childhood Vaccines” a two-page parent information sheet available free to physicians (see p. 29). 

National Network for Immunization Information
www.immunizationinfo.org

Offers a downloadable information kit for communicating with patients about immunizations. Includes fact sheets, talking points, and visit-specific printouts.

Childhood Immunization Support Program
www.cispimmunize.org

A Web site of the American Academy of Pediatrics that includes a compendium of national and state vaccine resources. 

National Partnership for Immunization
www.partnersforimmunization.org

Published by a public-private partnership that includes drug companies. Includes a reference guide on vaccine and vaccine safety that includes sections on regulation of vaccines and questions that should be asked about research studies.

Minnesota Resources

Minnesota Department of Health (MDH)
www.health.state.mn.us/immunize

Up-to-date information about vaccine shortages, immunization schedules for children and adults, forms, pamphlets, and posters.

MDH Immunization Hotline
800/657-3970

Staffed by public health professionals who can answer questions about immunization schedules, contraindications and precautions, administration, vaccine storage and handling, and other issues.

Vaccine Safety and Adverse Events Reporting

Johns Hopkins University Institute for Vaccine Safety
www.vaccinesafety.edu

Features links to research articles on vaccines.

Food and Drug Administration (U.S.)
http://www.fda.gov/cber/vaccines.htm

Includes information about the Vaccine Adverse Event Reporting System (VAERS), how to report adverse events following vaccination, the FDA approval process, along with FDA bulletins on vaccines.

Vaccine Adverse Event Reporting System
www.vaers.org 

Provides VAERS information, data, and report forms.

World Health Organization
www.who.int/vaccines-diseases/safety

Includes a section for health care providers on dealing with adverse events following immunization.

Antivaccine Information

National Vaccine Information Center
www.909shot.com

Provides a look at the concerns and reasoning of parents opposed to vaccines.