Posted by: notdeaddinosaur | January 11, 2011

The Slippery Slope of Anti-Vaccine Complacency

I got a package in the mail today: my very own (complimentary) copy of Paul Offit’s new book, Deadly Choices; How the Anti-Vaccine Movement Threatens Us All. Needless to say, I can’t wait to read it. Not coincidentally, Dr. Offit has been making the rounds of interviews in the wake of the book’s release. Although I haven’t heard any of them directly, I did see a reference to this NPR interview on the FaceBook page of an old friend, who quoted from it thusly:

IRA FLATOW:  You write that some pediatricians will not see kids who are not vaccinated. Is that a good solution to the problem?

Dr.PAUL OFFIT: I don’t know what’s a good solution to that problem. And I feel tremendous sympathy for the clinician who’s in private practice. On the one hand, and my wife sort of expressed this, she’s a general practitioner, a pediatrician, you know, she’ll say, you know, parents will come into her office and say I don’t want to get vaccines, including, for example, the Haemophilus influenzae vaccine, which is vaccine that prevents what was, at one point, a very common cause of bacterial meningitis.

And, you know, we’ve had three cases or three deaths, actually, from this particular bacterial form of meningitis in the Philadelphia area just in the last couple years.

And, you know, to her, it’s like, you know, let me love your child. Please don’t put me in a position where I have to practice substandard care, which can result in harm, which can hurt your child. Please don’t ask me to do that.

And I certainly understand the sentiment. On the other hand, if you don’t see that child, you know, where does that child go? Do they go to a chiropractor who doesn’t vaccinate?

I think it’s hard because then you lose any chance to really immunize the child.

Italics above are those of my friend. He then offers his take, that of a pediatrician in private practice:

We never hear what the “other hand” is. I fear, for Offit, there is no other hand. Let me suggest what the other hand might be: some pediatricians, such as yours truly, respect the right of parents to make informed decisions on behalf of their minor children. In the absence of a clear and present danger, such as an epidemic, neither I, nor the government for whom I work, can coerce parents into vaccinating if they don’t want to.

Oh, dear.

I, too, have families who are reluctant to vaccinate. No, I don’t dismiss them from my practice, because, as Offit says, then I lose any chance to educate them about the advantages of vaccination and the fallacy of their position. And my old friend is right: none of us can compel reluctant parents. But my responsibility it to their children — my patients! I must continue to make it clear to them that I do not agree with their decision not to vaccinate. Acceding to their demands without clearly communicating my reluctance to do so, what my friend calls “respecting the right of parents to make informed decisions on behalf of their minor children”, is abdicating that responsibility.

What if a family decided that they didn’t want to confine their baby in a car seat? The baby cries whenever they strap him into it, and besides, accidents are rare. They’ve done their research, and they feel the baby is safe enough in the mother’s arms. Would my friend be as sanguine about that decision?

What if parents did their own nutrition research and decided to put their toddler on a low fat strict vegan diet? As doctors, we are well aware that such a regimen would put that child at serious risk of significant malnutrition. Do we still have to “respect the right of parents to make informed decisions on behalf of their minor children” when they’re threatening to stunt their child’s growth? Wouldn’t we make every effort to educate them about more appropriate nutritional choices for their youngster? More importantly, would we ever stop trying to convince them they were wrong?

Where’s the line between “respecting the right of parents to make informed decisions for their minor children” and protecting the children from the consequences of their parents’ poor decisions? I submit that supporting parents’ bad decisions is a very bad decision in and of itself. Just as we can’t convince everyone to get a flu shot, we still have the responsibility to come right out and unequivocally recommend them.

Vaccination is important. Parents’ reluctance to immunize is generally based on flawed information. As physicians, it is our duty to educate our patients and their parents to help them make better decisions, not support their ignorance under the guise of “respect”.

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Responses

  1. […] This post was mentioned on Twitter by Bora Zivkovic. Bora Zivkovic said: The Slippery Slope of Anti-Vaccine Complacency http://bit.ly/hJgERT […]

  2. Hi, this response is unrelated to this blog topic, but thought I’d ask here. Can you do a post on what procedures constitute a thorough physical, in your opinion? I haven’t had one in several years and thinking of making an appointment now. The last doctor I went to didn’t even listen to my heart or go though the motions with feeling my belly and that stuff. And of the last 3 doctors I went to, I realized they didn’t bring up my immunization records. Is this usually left for the patients to bring up on their own? I’m not sure what to ask for when I go in. Thanks and love your blog 🙂

  3. If I was the parent of a small child (which I’m not–the one around here is now 16 and cannot be considered “small” by any sense of the word), I wouldn’t bring my child to a pediatrician’s office who accepted patients who refused vaccines. A few years ago there was a measles outbreak in California, brought on by unvaccinated kids who picked up the virus in Switzerland, of all places, and brought it home with them. An infant too young to be vaccinated caught the measles from these kids in the pediatrician’s waiting room and ended up being hospitalized. The measles virus is very hardy and is airborne, and will survive for up to TWO HOURS in a place previously occupied by infected people. So no way, Jose, would I bring a baby into a waiting room of a pediatrician who doesn’t insist on vaccines.

  4. There is a great op-ed about the antivaccinationists in the 1/13/11 issue of the New England Journal of Medicine.

  5. Guitargirl, I understand why you are concerned, but I doubt that anyone would be able to absolutely protect their child from a similar occurence. Do you know any parents who ask for the vaccination records of other children on the playground? at softball games? in restaurants?

    As Dr. D pointed out, the only way to prevent the spread of diseases for which vaccinations exist, is to educate the parents. It might be a little more risk in the doctor’s office, but would result in a lot less risk in the broader world. Heck, a doctor’s office is where sick people go; any parent should watch that their children don’t pick anything up there.

    [Not to say I actually agree that vaccination is universally the answer; I’ve been know to refuse vaccinations myself, e.g. HPV]

  6. I am a family doctor practicing in Canada and our group of lawyers who represent physicians in the country have made it clear that by denying people care or not letting them into your practice based on their personal health care choices is frowned upon and could open one up to litigation for discrimination. It is, in my opinion, also unethical.

    I’m not sure that respecting a parent’s choice for their child is mutually exclusive with not offering education on the subject of vaccination. I strongly feel that if we are to accept a parent’s authority to make a healthcare decision on behalf of their child, it is our responsibility to ensure that that decision is an informed one. I think education and harassment or coercion are different things entirely.

  7. Being an old fart, I saw a lot of H. influenza menigitis as a resident and young doctor. There is a whole generation of parents and doctors that does not know what a horrible disease this is. Even with the best treatment available, children regularly died, and the survivors were often deaf or retarded or both. When the vaccine became available in the late 80’s my children got the first two doses I got my hands on. And you can by golly bet that if I knew of anyplace there were unvaccinated children, be it a doctor’s office, a playground, or anywhere else, my children would most certainly NOT have gone there. That’s not discrimination, it’s common sense.

  8. Somehow you went from the private practice physician’s suggestion that one “respect” the rights of parents to make decisions to the idea that a physician should “support” those decisions. There’s a big difference between “respecting” and “supporting.”

    I think the bright line here is that it’s your job as a physician to make the best case you can to the parents about the benefits of vaccination, but you can’t actually stick any needles into the kids until the parents agree.

    I wholeheartedly agree with the idea of vaccination, but I’m not at all sure that the vast number of vaccinations kids get in the tight timeframe recommended is as harmless as physicians suggest. Most parents aren’t unwilling to vaccinate entirely; why not prioritize a little with the ones who balk? Decide on a few vaccines you deem most critical and offer those first, and spread them over several visits. I think flexibility on both sides would go a long way toward resolving this. Yes, I believe children should be both buckled into carseats and vaccinated. But I’m not sure every child needs to be fully vaccinated against 40 different illnesses by age two.

  9. @Brighid- Wow!!! 40 different illnesses by age 2? Could you please tell me what those 40 illnesses are? ‘Cause that’s some vaccine schedule.

  10. Hyperbole (I hope). I don’t know what the exact number is. But I know when I helped take my grandchildren to their well-baby appointments, at every appointment the doctors wanted to administer 5-6 shots covering as many as 8 illnesses, including some illnesses I’d never even heard of. It would take the babies days to recover; they’d be listless, they’d have upset tummies, they’d be feverish and cranky — different reactions, but always you could tell for several days they didn’t feel well. My daughter-in-law eventually set a limit: no more than two shots per visit, covering no more than four illnesses.

    I have a friend whose son became a quadriplegic from an immunization he got as an infant in the 70s. Years ago I also knew of a couple (friends of friends) whose child suffered some terrible reaction to a vaccine and wound up with a brain injury. They got some compensation from the special vaccine court, but it wasn’t really enough to cover their expenses. The risk of vaccines is very small, and as I say, I believe in the benefits. But the risk is real, and I don’t see the virtue in making a 4-month-old miserable with so many vaccinations all at once.

  11. Well, then Brigid, I would suggest that you actually check out the CDC recommended vaccine schedule, located here: http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2010/10_0-6yrs-schedule-pr.pdf

    You will see that by age two, it is recommended that children be immunized for exactly 15 disease. Not 40. There are only 2 vists where a child might have gotten as many as 5 shots (the two month and four month visits). That’s it.

    I think you need to do a lot more research before many any statements about vaccines.

  12. I really hope you do not put all kids on a vegan diet in the same pot, or rather their parents.

    My child has some rather serious health issues which we realised when she was 4 months and we started with different foods.

    I can tell you that were some tough months until we found a specialised doc and realised what was wrong.
    It is an intolerance to different protein markers and also Crohn´s disease.
    We are not entirely sure what else may play into it because she is still very young and as long as her health is good we(us and the doc) do not want to stress her with more invasive tests.

    So yes, she is on a vegan diet and is getting everything her body needs. Our pediatrician is very happy with her development, he also told us she is one of the happiest, healthiest children he knows.

    She never needed antibiotics and never was badly ill. She had a stuffy nose sometimes and sometimes for a couple of days a slight fever.
    The only times we nearly had to take her to the ED was when people thought a tiny piece of pancakes with animal milk or a piece of milk chocolat would do no harm.

    Fish causes the least reactions but because her body could develope more severe reactions like it happend with eggs, we were told to not feed her animal based foods.

    No, she does not get iron or calcium supplements.
    If one is informed about nutrition it is relatively easy to get all the needed nutrition through a wide range of different foods.

    The only thing we supplement for her is B12 because it is produced by bacterias and thus found in animal based products.
    There are some sources like hawthornberries which contain as much B12 as liver through bacterias in the skin of the fruits.
    But we stay with supplements because better safe than sorry.

    Now it is 4 and a half year since she is on a vegan diet and it is easy.

    Yes, it is easy to feed a kid everything it needs on a well thought diet.

    And it is very easy to malnourish a child on the common omnivore SAD diet.

    I worked in the health care area and it was sad what some parents feed their kids on a regular base and thought everything was fine.

    Kids can get malnourished on any diet, no matter of omnivore or vegan if the parents are not informed.

    How much children with diet based problems do you see?
    Bad teeth, too much weight, diabetic kids…

    If you give a diet a bad stamp because the parents do not care about nutrition, you also had to say that an omnivore diet can lead to malnutrition with deficites in vitamins, minerals, fiber and other stuff and is not recommended for a child.

    But that is not the fault of the range of foods, the problems is what parents pick.

    Child does not want to eat vegetables, so the parents do not feed vegetables.
    White bread, bought snacks, sweets and microwaveable menus.

    Just take a lok what is in most frozen meals that kids prefer and get feed.
    Mac ´n cheese, pizza, lasagne,hot dogs, burgers, pop tarts…you name it.

    Processed cheese and meats, bleached flour, hydrogenated fats, sugar.

    The only vegetable they eat is in the tomatoe sauce, maybe some single onions and carrots, the gerkchen and onions on the hot dog if you are lucky.

    My daughter does not eat every vegetable, sometimes she likes it, the other day she does not want what she ate the week before with gusto..so she eats an other vegetable.

    We have a wide range of foods for her so there is never the need to get stern with her to eat her vegetables.

    Our freezer is packed, but that makes it so easy, just thaw and cook the desired foods, use whole meal in pancakes but also different flours like oat, buckwheat, nut meals, quinoa…things other kids rarely might get but are packed with nutrition.

    The only things that are sometimes difficult are other people who think that it can not be so bad and give her something forbidden.
    I cured her grandfather from giving her forbidden threats(because the poor child is not allowed what other kids eat) when she had an attack because of a piece of pancake and he had to stay awake during the night and listen to her painfull screams. I stood in front of his door with my ill child and forced him to take care of her and see with his eyes how bad it can be.
    We have medication for such cases but when we do not know early enough that she had something bad she will have an attack and the medication can not take away all the pain and problems.

    I am so sick of people who think I forbid her things just out of fun or that she needs this and that to be healthy when we know that it will cause her to get ill.

    She can have her fair share of sweetsckaes, cookies and chips and lemonade,just not everything.
    It is the same with all children, children are not allowed all sweets or can eat them all the time.

    Same with my daughter, but the reasons why she can not eat snacks and sweets all day round are much more severe than for other children.

    What if people feed a diabetic child cake and sweets because the poor child is deprived of sweets because of the evil, evil parents…

    Stupid way of thought?

    Parents whose child has phenylketonuria are in a similiar bad situation, even worse than mine i think because I have it easier to feed her.

    I just have to keep an eye on animal products, the parents who need to look out for phenylalanine have it harder because this amino acid is everywhere where protein is.

    I wish people would be more understanding with such things and not sabotage the childrens health because they think a bit is not bad.

    What about a peanut allergy? Same bullshit….much better known, but still people are astoundingly ignorant.
    What, the chocolat bar contains peanuts? How should I know?

    Look at the back…there it stands in glaring letters!
    Are these parents depriving their child the joy of eating a peanut butter and jelly sandwich because they are evil?

    No, because it is bad for the health of the child.

    Do not put all people that are on a vegan diet in the same pot…the problem is not vegan or omnivore or atkins, the problems are all the people who do not care for nutrition.

    They think it will be enough to eat something ot eat something not and everything is fine.

    That a diet with burgers, fries and coke does not get healthy without the meat is what they do not realise.
    It was not balanced before, it is not balanced now.
    It also will not get healthy if you get it sugar free without the bun.

    What most people do not realise that a plant based diet is not vegan when it is not balanced.
    The vegan way of life lays great weight on a well balanced, wide spread diet which provides all the needed nutrition.

    Sadly I know more healthy vegans and vegan kids than omnivore people and kids.

    What I have seen with vegan people is that they research more thoroughly about nutrition and different foods.

    Sure there are some people jumping on the bandwagon because of a hype, because it is cool..and these are the people who have a bad experience and are shown to us in the news because they do not care to get more information or improve their diet.

    I wish people were more open, but also that people would inform themselves more.
    That´s a problem with every diet.
    But vegan diets are more criticised because it sounds so exotic and there is only a small number of people.

    Some priests molest children…so do all priests molest children?
    Many people get ill on an omnivore diet, so it is bad per se?
    American staffs attack people and kill them, so are all american staff terrier bad?

    Or is the real problem somewhere else? Not the food, not the dogs, but the people.

    A handfull of people is dragging all the others under.

    20 years ago a vegetarian diet was said to be unhealthy and lacking nutrition, now most people do know that this is not true.
    Sure there are still people who will eat fried onion rings, fried cheese sticks and white bread with ketchup or a similiar unbalanced vegetarian diet.

    Again not the diet per se but the people.

    But nowadays most people know that a vegetarian diet is healthy, more and more docs will tell people to try a vegetarian diet for their health problems.

    I hope in 20 years it will be the same with a vegan diet so my daughter has not to go through the same problems if her children have the same conditions as she had.

  13. Marni, I don’t mean to be getting under your skin. I told you 40 illnesses was hyperbole; you agreed with me that there are times when infants are supposed to get more than two shots for each little thigh. (And if you’ll look back at that schedule, you might notice that the “recommended range” thing offers several more opportunities for multiple shots besides the 2-month and 4-month visits where 5 are specifically recommended. Seriously, my older grandchild got a handful of shots for several visits in a row until my daughter-in-law began rebelling because it made the baby so sick.)

    At the risk of antagonizing you, my point was simply that when I was a kid in the 50s, we got several DPT shots and a smallpox vaccination. One of my cousins caught typhoid fever from drinking well water, and since our water came from a well (albeit a covered well with an electric pump), out of an excess of caution my mother got us typhoid shots as well. When I was in elementary school, polio vaccine came out and we got that. By the time MMR came out, I’d already had all those illnesses.

    When my son came along, he got DPT, MMR and polio. Smallpox was gone by then and typhoid was never an issue because we didn’t have a well. I don’t remember whether the chickenpox vaccine was around, but since he caught chickenpox as a toddler, it didn’t really matter. I don’t think it matters anyway; both my granddaughters were vaccinated for chickenpox but got the illness despite the shots.

    In my time and my son’s, the requirement was that we be vaccinated by the time we started school at age 5 or 6.

    Kids today are vaccinated against many more illnesses and on a much more compressed schedule. I’ll say it again; it made my older granddaughter sick each time it happened. I understand the benefits of immunization. I believe in vaccinating kids, I really, really do. But perhaps there’s a middle ground between parents who want to allow no vaccinations and doctors who hold up a fist full of needles.

  14. @brighid

    One smallpox vaccine that you received in the 50’s contained more antigens than the entire current vaccine schedule.

  15. I fully plan to not accept nonvaccinators. I owe it to other (and sometimes immune-suppressed) patients who might be in my waiting room.

  16. This is mostly aimed at Guitargirl RN, but in general as well.
    My children’s Pediatrician had 2 waiting rooms- a “sick” waiting room, and a “well” one. They were both separate rooms, and also separated from the check-in desk. Made it very easy to “avoid” having my non-vaccinated (yet!) babies and older “yearly health check” children from coming in contact with the other kids with health issues. As you checked your child in- you were directed to the appropriate waiting room. I never, ever worried about my kids “catching” something from another kid there- and that was a blessing when they are young and vulnerable.

    FYI- I had all 3 of mine vaccinated for whatever was available at the time. ( ie- youngest had the chickenpox vacc., but the 2 older didn’t because they’d had chickenpox by then!)


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