You are performing a postoperative check on a 1 year-old girl who required myringotomy and ventilating tubes for recurrent episodes of acute otitis media. After you apprise the parents that both tubes are in place and appear to be patent, they look at each other and then ask if you have time to speak with them about another health matter. You, of course, agree. The child’s mother begins to relate their long-time concerns about forthcoming decisions regarding childhood immunizations and the possible risks associated with these vaccines.
They have broached this topic with the child’s pediatrician on several occasions, but the pediatrician was adamant that if their daughter was to be his patient, she would have to be immunized according to the CDC-recommended immunization schedule. They are hopeful that you will be able to give them your viewpoint as a physician with a large number of pediatric patients. You take a moment to reflect on what you know about vaccines and the issue of vaccination hesitancy.
Until the last five years or so, you have taken for granted the fact that an appropriate number of children are being vaccinated according to the recommended vaccination schedule, and that the vaccination rate in your community has been sufficiently high. However, you have heard complaints recently from your pediatrician and family medicine colleagues regarding increasing hesitancy by young parents to allow their children to be vaccinated.
You have been in practice long enough to have seen the positive benefits of vaccines in reducing the risks of congenital rubella, meningococcal meningitis, epiglottitis, whooping cough, and a host of other serious illnesses that were more common early in your training. In fact, you are so thankful for the immunity imparted by these vaccines that you are quite puzzled when parents are hesitant to have their children vaccinated. Yet, you feel it is important to listen to the parents’ concerns and determine how to advise them.
How would you handle this case?
From the time the first vaccines were licensed in the U.S. in 1914–1915 (for tetanus toxoid, rabies, and typhoid), there has been a steady expansion in the research and development of additional and improved vaccines, including the latest 9-valent human papillomavirus (HPV) vaccine in 2014.
Public health initiatives over the past century have responded to outbreaks of serious diseases that have been tamed or eradicated through the use of vaccinations. The outcomes have been so successful that the federal government, through the CDC, has developed recommended immunization schedules, which are periodically updated based on new research findings. While the federal government does not mandate immunization regulations, each state has its own mandates and exemptions, which vary widely across the country. In most states, the immunization requirements are mandated through public school attendance requirements; some private schools do not require proof of vaccination status.
Exemption requests typically fall into three categories: medical, religious, and philosophical. It is important for the otolaryngologist in this scenario to ascertain the basis for the parents’ concerns and address them as professionally appropriate. Typically, parental concerns regarding vaccinations tend to rest on the possible adverse effects of vaccines on the child’s developing immune system; the “overwhelming” dosage of combination vaccinations; the presence of additives, such as thimerosal, that have been used in some vaccines; and occasionally, financial constraints and lack of access to healthcare resources.
Otolaryngologists are not tasked with the actual responsibility of immunizing children; however, the fact that vaccines currently in clinical use have greatly reduced the severity of many diseases common to the history of this specialty means that otolaryngologists do have a stake in the discussion.
Explain Herd Immunity
The otolaryngologist should determine the parents’ knowledge base about the science of vaccinations and their importance in public health. In the minds of the parents of a young child, even the rarest side effects of a vaccine can become a serious concern. It would be helpful at the start to review for them how many millions of lives over the past century have been saved because of vaccines, along with the serious nature of the diseases they prevent or lessen in intensity. The otolaryngologist can describe the serious diseases she has seen or learned about over the course of her career that have been curtailed, mitigated, or prevented by microbe-specific vaccinations, and the suffering of children that has been greatly alleviated. Examples from one’s professional experience are often very powerful tools in such discussions.
The science of “herd immunity” should be explained to the parents in terms they can easily understand. In general, herd immunity occurs when a sufficient rate of immunity, through vaccinations, is achieved within the community to greatly reduce the risk of infection in not only those immunized but especially in those persons who have not been immunized. Each infectious disease entity has its own threshold of immunization rate for producing herd immunity, based in part on its basic reproduction factor (contagiousness).
An informative exercise for the otolaryngologist, as well as the parents, is to access the NIH Disease Transmission Simulation site, which, given a certain infectious disease, can show how the rate of infection can vary with the percent of community immunization (available at science.education.nih.gov. If one were to use the following data in the simulator for a measles outbreak in a community—0.1 virulence rate (likelihood of dying from the infection), 10-day duration of infection, 9.0 rate of transmission—and observe the resultant spread of disease through the community population comparing 70%, 80%, and 90% initial immunity rate, it is obvious that 90% herd immunity would be required to reduce the spread of disease below the level of an “epidemic.” This is very convincing, graphic evidence.
Vaccine hesitancy is very complex and is dependent upon the context of the particular family perspective and health status. Primary factors in hesitancy are misunderstanding and misinterpretation of the science of vaccines, as well as misconceptions furthered by social media and unsubstantiated “reports.” For example, it is agreed in the legitimate scientific community that rigorous meta-analyses of available data do not support vaccinations as a cause of autism—yet parental concerns persist. It is true that vaccines are not without risks; however, the risks are very rare, and vaccines are heavily regulated by the appropriate federal agencies to comply with high safety standards. Substantial risks are quickly investigated, and action is taken to identify the potential problem, and is followed by appropriate remediation.
The CDC has developed a number of excellent publications related to “common vaccine safety concerns,” and “why immunize your child,” to which parents can be directed for thoughtful consideration. The American Academy of Pediatrics also has numerous resources for parents and physicians with regard to vaccination hesitancy (Pediatrics. 2016 Sep;138(3). pii: e20162146).
Some parents may be considering not immunizing their children at all. Others may voice concerns that the immunization schedule is too intense or concentrated, and are seeking the option to spread out the immunizations over a longer period of time. In response to those parents who may plan not to immunize, physicians are encouraged to explain the notion of a “social contract,” wherein families who do not immunize benefit from the “herd effect” of other children’s vaccinations, while not having to bear the slight risks. Additionally, if the children do contract a virus-specific infection, they could potentially infect babies and immunocompromised individuals who are not immunized for medical reasons.
It is important for physicians to emphasize the often terrible outcomes of infections in the non-immunized, and to help parents realize that these diseases are to be avoided for good reasons. And although it is a difficult ethical dilemma for physicians who are tasked with immunizing their patients to refuse to accept or maintain children in their practices whose parents will not allow them to be immunized, it does occur. The decision appears to be one of individual professional conscience.
Some pediatricians and family physicians are becoming increasingly amenable to discussing modifications of the vaccination schedule for children of parents with strong concerns about the density of immunizations. However, any acquiescence to a modified schedule must be accompanied by a very strong informed consent acknowledging that the child may well be at higher risk for contracting one of the infections in question, owing to decreased immunity at a given point in time. Given a choice between no immunizations and a modified schedule of immunizations, the latter is preferable. At this time, regulatory agencies in this country offer no specific guidelines regarding modifying the recommended schedule of immunization.
The Role of Otolaryngologists
Otolaryngologists are not tasked with the responsibility of immunizing children; however, the fact that vaccines currently in clinical use have greatly reduced the severity of many diseases common to the history of this specialty means that otolaryngologists do have a stake in the discussion.
The appropriate responses we can give to parents wishing to discuss their vaccine hesitancy may include:
- Listening carefully and with empathy;
- Educating the parents about the diseases that vaccines prevent or reduce;
- Helping them to better understand the science of immunization and herd immunity; and
- Emphasizing the importance of the social contract for community public health to which we all are obligated.
These are delicate discussions, and a balance must be maintained between affirming the parents’ right to make decisions for their children, and stressing their responsibility to understand the facts as we know them about the salutary effects of immunization. Information gathering and sharing between the parents and the otolaryngologist should occur in a respectful, interactive environment, with the best interests of the child/children always at the forefront.
Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.