Alternative Vaccination Schedules

Evidently the 7 billionth human is going to be born on October 31. Happy birthday and welcome to the Earth.  If you were unfortunate enough to be born into a developing country or a affluent California family, you may not receive your vaccinations, and may join one the 57 million who die each year of vaccine preventable diseases (VPD).

I totally misread the table.  It’s about 4,320,000 who die of VPD. Well, I said I was no damn good at stats.

And if you are doubly unlucky, you may be exposed to illness from an unvaccinated friend, family or health care worker before you can get your vaccines, and join the ranks of the ‘only’s.’  The ‘only’s’ are those who die of vaccine preventable diseases and are mentioned in anti-vaccine literature in a sentence like ‘VPD X is a mild illness in most children and only kills Y% of cases ’.  As I have said before the anti-vaxers do not care for whom the bell tolls.

I am no good at statistics.  I signed up for, and dropped, statistics at least 4 times in college.  Once they got past the bell shaped curve, it was one incomprehensible huh?  Part of the problem with statistical concepts such as risks, both relative and absolute, is that it is often impossible to get a feel from what they represent. For me it is like metric measurements.  I know what a 8 mile hike represents, but not an 8 kilometer hike.  Same with centigrade and liters.  I have been unable to internalize what metric means in my daily life.

Some statistics I have to accept with no real feeling as to their magnitude.  That estimated 57 million deaths from vaccine preventable illness?  That’s a number I can’t wrap my head around.  It translates to about 148,000  11 000 day, or the population of my home town Portland, dying every two days month.  I (still) can’t imagine that volume of death.  In 30 years I have seen exactly one death from a VPD,  a pregnant female who developed chickenpox and its resultant pneumonia.   Chicken pox, hepatitis A and B, and pertussis are the only viral VPD’s of which I have seen more than one case.   The only vaccine preventable illness I see routinely, and I should put preventable in quotes because I am not so sure the disease is currently preventable in adults, is the Pneumococcus.  Certainly vaccination of kids with the conjugate vaccine has lead to a decrease in disease in adults, but that appears to be a temporary victory and the vaccine for adults, the Pneumovax, is of marginal efficacy.

I know intellectually that VPD’s are a major source of morbidity and mortality in the rest of the world, and that they, along with many other infections,  are an airplane flight away from starting an outbreak.  It has happened with mumps and measles, and it will happen again.  But VPD’s have virtually no impact on my day to day experience as an infectious disease doctor and as head of our Infection Control programs.  My time and energy are directed elsewhere.

What are parents to do?  When raising kids in the US there is no need to worry directly about VPD’s. It is more a theoretical worry,  because thanks in part to vaccines, the childhood plagues of the past are history, and who needs to fret about history when there are real risks to your children.   I wonder, given the hassle of getting the kids to the pediatricians, how compulsive I would have been about getting my kids vaccinated on schedule if it were not a requirement for school.  I  probably would have kept reasonably on track, like my dental cleaning, but would not have been the model of promptness, given the lack of VPD’s in the community.  It is nice to have the stick of the educational system keeping us honest, and the schools are wise to have immunization as a condition of enrollment.  Schools represent an excellent center for rapid infectious disease amplification and spread.

Laziness is evidently not the main reason that parents do not get their kids vaccinated according to the CDC guidelines.  Pediatrics this month has an article, Alternative Vaccination Schedule Preferences Among Parents of Young Children, that evaluated why parents are using alternative vaccine schedules. They polled the parents of kids between the ages of 6 months and six years of age about their utilization of the vaccine schedule, and I can’t decide if the results are good or bad, given the large number of irascible contrarians in the US population. Or perhaps I watch too much cable news. I am an optimist at heart so  I suppose the glass is half full, albeit with bile.

13% of parents interviewed were using an alternative vaccination schedule, but  only 2% refused all vaccinations.  Most, rather than no vaccination, refused some vaccinations or waited until the children were older before giving the vaccination.  So is 2% complete refusers, a low number or a high number?  Does 13% qualify for an only? Is 87% great?  Well, no.  For most diseases, the coverage rates you want to maximize herd immunity for those who cannot be immunized is in the 95% plus range.  I always emphasize for the housestaff that the first word in my medical subspeciality is infectious.  Not kind of infectious or sort of infectious.  These beasts have evolved to rapidly jump from person to person and it takes very little exposure for them to cut loose in populations.  In the old days my field was called contagious diseases, and I kind of prefer that title, even though most of the diseases in the hospital are no longer particularly contagious.

Good news: “Among the alternatively vaccinating parents, only 8% reported using a well-known alternative schedule, such as those promoted by Dr William Sears (6%) and Dr Donald Miller (2%).”  It would appear that the advice of Dr. Sears et. al. is being mostly ignored by the alternative vaccinators.

Bad news: However, with true American do-it-yourself Dunning Kruger gumption,

it was more common for alternative vaccinators to indicate that they themselves (41%) or a friend (15%) had developed the schedule. Among the 36% of respondents who endorsed the “other” response to this query, several indicated in the free-text section that they had “worked with their child’s physician” to develop the alternative schedule.

A do-it-yourself vaccination schedule.  It flabbers my gaster.  Having spent most of my adult life thinking about infections and their treatment and prevention, I find the field almost impossibly difficult.  The decisions that go into the CDC vaccination schedule represent the best opinion of some the brightest and most experienced minds in medicine who are not me.  Joke.  Really.  I would only question the CDC if I had spent three professional lifetimes in the field of vaccinations.  And yet time with the googles and talking with friends and family is evidently enough to come up with your own approach to the vaccination schedule.  I am glad these parents are not also responsible for deciding on doing an appendectomy or piloting my airplane.  I have asked this in the past, but what is it about medicine where people think they can know better with no experience and little education?  It is my field of expertise and I am more often in not uncertain if I know better.

It would appear that physicians may be a bigger problem.  Co-dependent is the term, I think.

While 8% had to change providers because they wanted to use an alternative schedule and

30% their child’s doctor “seemed hesitant to go along” with their vaccination preferences but still agreed to do so, 40% indicated that their child’s doctor “seemed supportive” of their vaccination preferences, and 22% indicated that their child’s doctor had been the one to suggest using an alternative vaccination schedule.

Of 2064 respondents, 59 (22% of 13%) found a physician who recommended an alternative schedule.  We do not know if that was a bias (parents knew about that providers dirty little secret when choosing a doctor for their child) or the number of docs promoting potentially dangerous vaccination schedules is much higher than I would have thought.   Still, that is almost 3% of doctors who are, well, wackaloons.  3% is not an only. 3% is appalling. Would you want 3% of your surgeons to have a severe shake or 3% of your pilots to have narcolepsy?

It is interesting to see what vaccines the parents elected not to give to their kids or delay in giving.

It reminds me of the Eisenberg article in the NEJM where it was purported that 35% of Americans use alternative medicine.  When you look at the data, it is only by  using an extremely broad definition of unconventional including relaxation techniques and commercial weight loss  programs could the 1 in three statistic be reached.  Real wackaloon therapies like homeopathy and energy healing were in the 1% range.  I found that table of unconventional medicine use in that continually favorably spun article reassuring, not worrisome.  Americans are not as gullible as the SCAM proponents would wish.  I try and keep that in mind when I watch Presidential debates.  Repeat after me.  Americans are not THAT gullible.

Even though AOA, Jenny McCarthy  and others have worked hard to spread fear about vaccinations and have gladly taken credit for that fear, it appears that the message is not as effective as they might wish.

The list is, very arguably, reassuring.  As far as the disease severity is concerned, the list is roughly in order of morbidity and mortality risks for kids. If I had to rank vaccines in the order I would give them up if forced, that is about the order I would do it.  I would give up flu vaccination first and polio and pertussis last, although it is akin to deciding in what order I would like organs removed.  I really would just as soon keep them all, thank you very much.

However, a glass 6 to 86% empty, it is still not full.   Herd immunity and the group benefits are, I know, a poor reason to recommend vaccination.  Presidential politics reminds me that there is always a strong ’screw you’  sentiment in the US. I only saw it on the Daily Show, but I think Ron Paul being asked if he would let an uninsured patient trauma just die the archetype of that attitude. Being your brothers keeper is low on the US to do list, and if my child’s lack of vaccination leads to someone else illness and death, so be it.  There was  a time when the concept of a rising tide lifting all boats was a public health concept embraced by most, when we worked together for the common good.  A life in medicine has definitely demonstrated that that idea, if indeed it was once alive, is dead and buried with a stake in the heart, beheaded and covered in garlic, not that health care and public health is a vampire.

The attitude of ‘me first’ is oddly seen in health care workers, as I subscribe to the idea that in medicine you have an obligation to always put your patients first. Despite hospitalized patients being particularly susceptible to acquiring influenza, that about 1 in 5 cases of flu are subclinical and if acquired in the hospital, the patient has a 27% chance  of dying of flu, 36% or more of HCW’s refuse the flu vaccine each year.  It is not as if they have some special knowledge that prevents them from receiving the flu.  They give the same old dumb ass reasons every year.

Still, even small decreases in vaccination rates have disproportionate adverse consequences, as “1% increase in the proportion of school-aged children who were underimmunized, the risk of pertussis infection among fully vaccinated children doubled.”  I would wager that there are similar ill effects from avoiding other vaccines; it would seem plausible.  But how does a parent understand the abstract concept and act accordingly when there is no disease in their immediate environment?  Only Sherlock Holmes was wise enough to understand the significance of the dog that did not bark.  I had a similar problem with hand hygiene for years, the lack to understanding that not washing hands today leads to an infection tomorrow. It took a decade of intensive work as well as a change in how hands are hygienated  (from soap and water to alcohol foam) to take rates from 20% to 95%, although I suspect the real driving force was the knowledge that infection rates were going to be published for all to see.  Impending public embarrassment is a powerful motivator.

The main reason (61%) of  parents altered the vaccination schedule is ‘it seemed safer’.  It is better to feel safe than to be safe; the spirit of Fernando lives on.  These parents were also more likely to see the risk of disease and transmission to be less, and have more non-mainstream vaccination beliefs; it seems that the  ‘too many, too soon mantra’, of the anti-vax proponents is resonating with alternative vaccinators.  If there is a fear of autism as a reason for changing the schedule, it is not addressed in the paper.  However by delaying the vaccinations past the age of onset of autism diagnosis, parents may feel safer in giving their children the vaccines.   It would have also have been interesting to know what particular fears and experiences lead to the use of an alternative vaccination schedules.

Rare adverse experiences, even if not casual, can have a disproportionate influence on future behavior.  I know clinically I remember bad outcomes with far more clarity than the successes.  Even when I know the complication were unrelated to my therapeutic intervention or a known, and rare, complication of care (like deafness from aminoglycosides from treatment of enterococcal endocarditis), where I can at least rationalize that it was the occasional misfortune that happens as part of even the best of care, on occasion I still have to fight the urge not to repeat the past intervention for fear of a repeat of the same complication.  It is hard not to give in to the fear, even when I know the fear is irrational.

It could be a lot worse.  The glass could have been even emptier.

…nearly 1 of 4 parents (22%) following the recommended schedule disagreed or strongly disagreed that the schedule “recommended by vaccination experts” was the best one to follow. Similarly, 1 of 5 parents who followed the recommended vaccination schedule thought that delaying vaccine doses was safer than providing them according to the recommended schedule.

I find that a curiosity,  that a significant number of patients were choosing to do something to their kids that they did not think was best for them.  There is no reason given for that choice, but there appears to be a sizable number of patients are at risk to opt out of the vaccination schedule if given the opportunity.  Equally curious is the 19% of alternative vaccinators who think delaying vaccination increases the risk of infection and spread of diseases, yet delay all the same.  Do they think that the risk of the vaccine is greater than the diseases?  They must, although the sign of an educated person is the ability to hold two contradictory thoughts in the head at the same time.

The preponderance of information in the medical literature on vaccinations is as clear as any topic in medicine.  Vaccines are effective and they are safe.  The best bet for keeping your child, and your community, healthy is to get vaccinated and to do it on schedule.  There are people who see the issue differently, and is often the case, the reasons are more subtle and complicated that one would except.  And there is still much to be understood as to why people do and do not participate in the vaccination schedule.

Posted in: Vaccines

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