Vaccine hesitancy comes in all flavors. It’s not always concerns about safety that causes children, teens, and parents to hesitate or even refuse vaccines. Sometimes it’s about pain. Or simply discomfort. Or anxiety. It’s perfectly natural, of course, to have a fear of needles. It’s rare that a child enjoys the pain of an injection (although those kids, even at young ages, are out there).
Sometimes the fear and anxiety of needles really can manifest itself as a sincere phobia. In those cases, the fear is so overwhelming that it changes family decision-making around vaccinations and leaves children unprotected. It can torture parents when they have to scoop their kids up from under the chair. And parents get embarrassed when their child/teen becomes combative with shots. Sometimes they avoid coming back to clinic simply to avoid the conflict. Makes sense in a hectic world.
However recently in clinic I took care of a teen soon after she’d had a terrible experience with Influenza (the “flu”) and it’s changed how I care for my patients. She was an asthmatic, high school student. Because of her asthma, her doctor had recommended a flu shot. Even though doctors recommend flu shots for all children between 6 months of age and 18 years, we work very hard to get high-risk patients protected. Children and teens with asthma are more likely to have a severe pneumonia after contracting Influenza. We worry about children who wheeze and have asthma (even mild asthma) because it can land them in the hospital and/or can cause a life-threatening illness.
Most parents with asthmatic children get flu shots yearly, early in the season. But not all.
When I saw the girl in clinic she was exhausted and stressed, confused and scared. Through the course of her Influenza illness she had missed 2 weeks of school and lost over 15 pounds. She was still coughing a few weeks later. I looked back to the chart note visit prior to her infection where her pediatrician had recommended the flu shot. “She’d declined,” it said.
I’ve just returned from a week in Idaho where I had the privilege to do a series of talks for the Idaho Department of Health (DOH) about using social media to communicate about vaccines. The best part of the week was all of the education I received. I traveled around the state (see those photos!), witnessed the DOH at work, connected with Idaho physicians & politicians & advocates & volunteers, and talked with many Idahoans about changing the understanding of vaccine science. Three times I heard Dr Melinda Wharton from the CDC present on vaccine safety. And more, in a matter of 4 days we talked with a clinician, nurse, or medical assistant from every single office in the state that provides vaccines to children. I mean, that’s a wow–a sincerely networked community circa 2012.
If all states had the opportunity to convene like they do in Idaho we’d really improve understanding, communication, and opportunities in health care surrounding vaccine safety and decision-making.
After arriving home to my boys, I’m compelled to share 3 things I learned in Idaho:
I think it’s essential that we talk about the risks associated with vaccines when we give them–each and every time. Dr Wharton discussed known risks to vaccines and the science to support those risks. She also talked about inferred risks that aren’t backed up with science (autism, for example).
The 2 month-old check up may be harder for parents than it is for babies. Getting the first set of shots is anxiety provoking for we moms and dads; no question that it’s unsettling to allow a medical provider to cause our beautiful, new, healthy baby pain. Research has found that the pain and discomfort associated with shots is one of the primary reasons parents “elect not to perform timely vaccination.”
A study published this week affirms two truths. First, structured soothing may be a great tool for families to control crying after discomfort from shots. A group of pediatricians in Virginia used Dr Harvey Karp’s Happiest Baby on the Block 5S’s technique (shushing, swaddling, side positioning, sucking, and swinging/swaying) as an intervention for crying after the 2 and 4 month shots. The technique has been advertised to parents as a way to soothe and comfort fussy and colicky babies in the first few months of life. The researchers found that compared to a control group with no intervention and a group of babies that received a sugary solution for comfort prior to the shots, the 5S technique helped soothe crying and pain more rapidly. Most babies that were swaddled, shushed, swung, and offered a pacifier for sucking stopped crying within only 45 seconds. Second, the great reality is that most babies stop crying within 1 to 2 minutes of getting injections anyway. The study confirmed that, too! In my experience, only rarely does a baby leave clinic still crying. Some of our anxiety about the discomfort as parents can be relieved–we really need to get the word out this is a short process. It’s rare for a baby to cry for even 3 to 4 minutes after their injections. Read full post »
This week, Washington State declared that whooping cough (pertussis) has reached epidemic levels. Since the beginning of the year, we’ve had more than 600 documented cases in the state, a dramatic increase since last year. The increase puts our new babies at risk.
In clinic I’ve been urging new parents to cocoon their babies. That is, provide a family of protection by having every single child & adult immunized against whooping cough, influenza, and other vaccine preventable illnesses. By surrounding a baby with only immunized people, you cocoon them against serious infections.
Whooping cough is a highly infectious respiratory illness spread by sneezing and coughing that can be deadly to young infants. Getting a Tdap shot is the best way to avoid getting whooping cough. Amidst an epidemic, we worry most about newborns because they are most vulnerable to complications and lack vaccine-protection. If every child and adult that surrounds a newborn gets a Tdap shot, the likelihood of the baby getting whooping cough approaches zero.
Most newborns get whooping cough from their family or adults around them. That’s where an email comes to play.
You’re going to have to be fairly Mama-Papa-Bear about this. You’ll have to show some strength to create a very safe home, even when it feels somewhat over-the-top. As I said to a number of families in clinic today, “It only seems entirely over-the-top-nuts until we lose another newborn to pertussis.” Being smart now will save lives.
Make a new rule: no visits with a newborn until all visitors have had the Tdap shot. Even Grandparents.
Write an email to family and friends to explain.
A sample email for you to use/copy/share –written today by a friend of mine–mother to that darling baby girl born last week: Read full post »
Some of my best friends are about to have a baby, the due date only a few weeks away. I’m teary thinking about it as my excitement for her arrival exceeds the speed limit. They asked my opinion this week for getting their extended family immunized in light of the recent Whooping Cough (pertussis) outbreak in our area. I advised them that all teens and adults (including grandparents) need a Tdap shot before they are with the baby. Even pregnant women are getting immunized after 20 weeks gestation to protect their newborns at and after birth.
Ideally, everyone should have the Tdap shot at least 2 weeks before the baby arrives.
My friends advised their parents. But both grandmas were turned away–one here in the US and one abroad. Each were told by a physician that they didn’t need the Tdap shot because they were over 65 years of age.
That physician was wrong. Whooping Cough (pertussis) knows no age. And immunization recommendations for pertussis protection have changed this past year because of rising rates of infection and infant deaths.
The best way to protect a newborn baby from getting Whooping Cough is to cocoon them with family and friends who are immunized against it.
All grandparents, all adults, and all teens need a Tdap shot before holding a newborn baby.
Ask questions, please. And one more thing, can you suggest girl names? My friend is beside herself that they don’t have one picked out…I’ll buy you coffee if you suggest the name she chooses (hint: use a real email)
Like the makings of a Hollywood movie, I learned this week that there were an estimated 200,000 people in Super Bowl Village this past weekend in Indiana. Amongst them on February 4th, was one (or maybe two) child with infectious measles. Fortunately, the child didn’t attend the game. Yet, measles is highly contagious. The period of infectivity starts before symptoms in some cases and usually 4-5 days before the typical rash, when many think they have just a bad cold. Measles is spread by the respiratory droplets infected people share when breathing, coughing, or sneezing. And the virus can survive for about 2 hours on surfaces or in the air after a person leaves the room. Measles has a wild history and although most children/adults do well after recovering from the illness, measles can result in severe complications like pneumonia or encephalitis. Fortunately, the majority of those in attendance last weekend who may have walked by or been near the infected person were protected by the measles vaccine.
The incubation period (the time it takes to get sick after being exposed) is about 10 days with measles. So if unprotected people contracted measles last weekend, they may get sick this weekend or early next week. Hopefully, we’ll hear of no one.
Measles spreads easily. There are reports of measles infecting every single unvaccinated person at a picnic. The public health department, even here in Seattle, sent an advisory email last night with instructions for what we doctors should do if we suspect measles in someone who was in Indiana last weekend.
But this is a global thing not just a US national sport thing. Starting in 2009, the number of cases of measles rose sharply in Europe. In 2010 for example, there were over 30,000 cases of confirmed, reported measles and in 2011 (through October), there were over 25,000 cases, with over 14,000 cases in France alone. Fifty percent of those with reported measles were children, less than 14 years of age. Immunization rates for measles have declined in Europe and public health officials point to waning vaccination as one reason for the surge. Read full post »
I had coffee with Dr Doug Opel last week to discuss his study about pediatricians and alternative vaccine schedules that published today. I learned a lot while we spoke. There is great wisdom in what he said (below in the interview & on video) that extends far past what he learned in the study.
Dr Opel is one of those genuinely authentic, kind people. The kind of person you meet and wonder, gosh if only I could be a fly on the wall when he’s making decisions for his kids or decisions for his life or decisions for his patients–I’d be so much better off. Not just because I’d see the answer, but because I’d have a front row seat while he asked the questions. He’s just remarkably thoughtful so there is no wonder this study illuminated some helpful observations.
Dr Opel and his colleagues conducted a survey of WA State pediatricians to find out how often they were being asked about alternative vaccine schedules and how doctors felt about it. Seventy-seven percent of pediatricians reported they are regularly being asked to use an alternative vaccine schedule. And in general, the majority of pediatricians (61%) are comfortable with alternative schedules but only for particular vaccines. Meaning that although pediatricians are okay with parents’ request to delay some vaccines (Hepatitis B vaccine or Polio) they are not comfortable waiting on others (DTaP, Hib, or PCV). The reason, Dr Opel suggests, is that pediatricians are unwilling to leave kids unprotected for potentially devastating diseases that still circulate in our communities.
In this interview, Dr Opel lends insight to the culture of concern about vaccine safety, how the changing health care environment has shaped how we ask questions in the exam room, and how the concern about autism and vaccines is simply emblematic of concerns about vaccine safety in general. Read full post »
I just responded to a New York Times “Armchair Ethicist” chat about pediatricians who refuse patients who don’t fully immunize. I realized my comment on their site belongs here on the blog. (my comment is number 79 but also copied below).
What do you think about pediatricians who refuse patients who don’t follow the AAP schedule? Do you disagree with me? Would you be more comfortable seeing a pediatrician who refused those families who chose not to immunize to protect your children? Have you, or someone you know, ever been kicked out of a pediatrician’s practice?
I’m a pediatrician (w a master’s degree in bioethics) and mother to 2. I will always keep my practice open to vaccine-hesitant families. However, the waiting room risk (unimmunized kids & risk to vulnerable populations–ie infants, those too young for vaccines, and immunocompromised children) is a good one and the only compelling reason to close to patients who refuse immunizations in my opinion.
But it’s not a good enough reason for me to send families away who have questions and hesitations about the AAP/CDC schedule. All children deserve a pediatrician versed in immunization benefit/risk & deserve an expert in conversation w their parents to foster insight & understanding. Frankly, if waiting room risk is the concern, there are ways to create separate waiting rooms for kids “up to date” and kids who are not.
Great thing is, only about 10% of families use alternative vaccine schedules. In a recent Pediatrics article, only 2% of families who used alternative schedules refused all vaccine altogether. So although this is a large issue in pediatrics and parenting, the majority of families do vaccinate on time or nearly on time. I don’t want to lose sight of that.
I practice in WA State. We lead the nation in exemptions for vaccines (over 10% of kids w exemptions vs only 2% nationally) and have recently put into place a law that requires families to consult with a health care provider prior to an exemption. It was designed to avoid exemptions out of convenience. This hopefully opens up the opportunities for discussions with parents & pediatricians!
We all want the same thing: healthy children, healthy communities. Fostering conversation and diminishing a context of “war” or opposition about immunizations is an important step. In my experience, most parents end up immunizing their children over time even when they start out as refusers. The group of full refusers is fairly small. So allowing all kids into my practice feels like a great opportunity.
Tdap is a shot necessary for all adults and children starting at age 11 that protects against infections caused by Tetanus, Diptheria, and Pertussis (Whooping Cough). Because of increasing reports of Whooping Cough and increased infant deaths in the last 2 years, we are working hard to protect infants, children, adolescents and adults from Whooping Cough (caused by Pertussis). Most importantly we want to protect our newborn babies from being exposed or contracting whooping cough. Whooping cough is most dangerous and most devastating (occasionally fatal) for newborn babies (under 2 months of age) and infants under the age of 6 months. If you are around a newborn baby it’s essential you’ve had a Tdap shot at least once as an adult. Watch the video for more.
Keep in mind, even fully vaccinated adults can get pertussis. If you are caring for infants or young children, check with your health care provider about what’s best for your situation.
WHEN TO CALL THE PEDIATRICIAN: Pertussis infection starts out acting like a cold. You should consider the possibility of whooping cough if the following conditions are present:
The child is a very young infant who has not been fully immunized and/or has had exposure to someone with a chronic cough or the disease.
The child’s cough becomes more severe and frequent, or her lips and fingertips become dark or blue.
She becomes exhausted after coughing episodes, eats poorly, vomits after coughing, and/or looks “sick.”
How To Protect Your Family From Whooping Cough
The best way to prevent Pertussis (Whooping Cough) is to get vaccinated.
Children 7 to 10 years old who did not have their full DTP/DTaP series (2,4,6, and 15 months shots) need a Tdap shot.
Children with either an unknown or incomplete shot record/history before age 7 years of age need a Tdap shot.
All adolescents with an up-to-date record need the Tdap shot at the 11 year old well child check-up/visit.
Anyone over age 11 who has not previously received Tdap – when indicated.
There’s no minimum interval between Td and Tdap vaccines. Meaning, if you for some reason had a Td (“tetanus booster”) in the last few years, you still need a Tdap now to protect against whooping cough(Pertussis). No 5-10 year interval is required between the shot.
Vaccine protection for pertussis, tetanus and diphtheria fades with time, so adults need a booster shot. Experts recommend adults receive a Td booster every 10 years and substitute a Tdap vaccine for one of the boosters.
Getting vaccinated with Tdap is especially important for adults who are around infants – new parents, grandparents, babysitters, nannies, and health care providers.
I see this as a glass half-full, glass half-empty issue. Yesterday, a study was published in Pediatrics detailing research conducted in May of 2010 about parents’ preferences to use alternative vaccination schedules versus following the recommended CDC vaccination schedule. The majority of the media coverage focused on the finding that over 10% of parents followed a schedule other than the one recommended by the CDC. Not perfect and not ideal from a public health stand point. Yet, of course, the other way to see this is that nearly 90% of parents did follow the physician-recommended schedule. That’s a pretty good success rate for doctors.
As a pediatrician practicing in Washington State, I saw this study half-full. As I read through the methods, results, and discussion, I took notes on the cover page. I actually made that little doodle. I couldn’t help but think about the nearly 90% of families (87%) who followed the recommended schedule to protect their children and their communities. Clearly 87% is not 100% (I get that) and it leaves our communities and our children at risk, but I believe we can continue to improve trust with ongoing education.
Focusing on the group that does vaccinate their children on the schedule may be a good strategy to understanding where we can improve our communication about the benefits of vaccination. We often focus on the group that doesn’t vaccinate but we miss insight from those of us who do immunize our children on the schedule.
Details: The study was conducted on over 2000 respondents, where 771 families qualified by reporting having a child between 6 months and 6 years of age. They were asked if they followed the CDC schedule and then if they didn’t, they were asked to answer a series of closed-ended questions regarding the nitty gritty of the schedule they used. Parents’ age, gender, race/ethnicity, and level of education and family insurance were collected.
Seattle Children’s provides healthcare for the special needs of children regardless of race, color, creed, national origin, religion, sex (gender), sexual orientation or disability. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.