HEALTH CARE PROVIDERS NEED TO DO A BETTER JOB TALKING ABOUT VACCINES
by Celine Gounder, MD, ScM
February 4, 2015
The United States is facing a nationwide measles epidemic, and it’s just beginning to take off. We now have the highest number of measles cases since the infection was eliminated from this country in 2000. Our triumph over measles in the last century is one of our greatest public health achievements. Before 1963, when the measles vaccine became widely available, three to four million Americans got measles each year, of whom about forty-eight thousand were hospitalized, four thousand developed encephalitis resulting in long-term brain damage, and four to five hundred died. But in the past two decades, more and more parents have chosen not to immunize their children, so much so that vaccination rates in some parts of the country are well below those seen in much poorer developing countries.
Parents want to do what is best for their children, and they are right to ask for help in sifting through information on vaccine safety. But the science on vaccines is very clear: they are safe and effective. Vaccines, including the measles vaccine, do not cause autism. However, parents’ decisions not to vaccinate don’t necessarily imply a lack of scientific understanding, but rather may reflect how they see the science as applying to their families.
We as health care providers are failing our patients. We don’t spend enough time listening to parents, who know their children and their families best. (Unfortunately, our health care system doesn’t value the time clinicians spend counseling their patients, whether it’s about vaccinations, diet, exercise or end-of-life care.) It’s important to take note of their concerns and personalize the recommendations we offer. While the vast majority of children should be immunized, some vaccines may be dangerous to a rare few: those with weak immune systems or a family history of immunodeficiency. Someone with a normal immune system can fight off the wimpy strain of measles that we use in vaccinations. But if you’re immunodeficient, even the wimpy measles vaccine virus can cause very real disease. If we don’t take the time to talk to parents, we’ll miss the kids who are at highest risk for complications. But it is also important to understand that the best way to protect those with weak immune systems is to vaccinate everyone else. If someone with a weak immune system is infected with the wild strain of measles circulating in the community rather than wimpy vaccine strain, they are likely to suffer worse disease and long-term complications.
Perhaps because health care providers don’t have the time or because they don’t think parents will understand a more nuanced discussion, they may be guilty of giving unqualified assurances that vaccines are risk-free. Rarely, measles vaccines may cause fevers and seizures(4 in 10,000)—which fortunately have no lasting effects—or severe allergic reactions (less than 1 in 1,000,000). Meanwhile, the risk of severe allergy to the antibiotic penicillin is 1 to 5 per 10,000, resulting in death in 1 to 2 per 100,000 persons. (It is common for children with the measles to be given antibiotics due to treat or prevent complications like pneumonia.) But even the most minuscule, justifiable risk may seem unwarranted when we don’t witness the risks of inaction firsthand, even if history and statistics tell us that the benefits of vaccinating far, far outweigh the risks of doing so.
When clinicians gloss over these risks they may seem dismissive, and so lose their patients’ trust—not unlike the U. S. Centers for Disease Control and Prevention did when it was overconfident about hospital preparedness for Ebola last fall.
It is normal for parents to want to protect their children from all unnecessary risks, no matter how small, and doing so in today’s world has become much more challenging. When they’re not sure, it’s simpler not to act, and they say, “we just don’t know,” “we can’t be sure,” and don’t vaccinate.
Some parents choose not to immunize their children because they think that vaccinations aren’t natural. They think that diseases help make an immune system stronger in a way that vaccines don’t. Or they think that vaccines are toxic. Vaccinating your child is one of the most natural things you could do. You’re priming the immune system to fight disease in a controlled, safe way. Vaccinating your child against measles is far more natural than giving them an antibiotic or putting them on a ventilator for pneumonia if they get measles.
There’s a short checklist of things to do if you want to lead a natural, healthy life: have access to safe water, hygiene and sanitation; eat well; exercise; get enough sleep; don’t smoke or abuse drugs; drink alcohol in moderation; get vaccinated; practice safe sex; wear your seatbelt; and brush your teeth. If you do these things, chances are, you’ll be healthy for most of your adult life. Even if you do everything else on this list and lead an otherwise healthy lifestyle, if you aren’t vaccinated, you leave yourself at risk for a number of infectious diseases and their complications.
There are also those parents who don’t want the government interfering in what they see as their freedom to raise their children as they choose. Risks loom larger when they’re imposed, as when a government that isn’t trusted recommends that children be vaccinated, and a pharmaceutical industry that’s seen as mercenary manufactures those vaccines. But transmission of infectious diseases isn’t just a question of personal responsibility. By not vaccinating their children, parents are putting others at risk too: persons with weak immune systems, infants under the age of one who are too young to be vaccinated, and pregnant women.
Unfortunately, too many politicians give us reason not to trust them, and by extension, the government. Presidential hopefuls like Governor Chris Christie (R-NJ) and Senator Rand Paul(R-KY) prioritize their popularity with potential voters over science and sound public health policy. Christie was quick to strip the nurse Kaci Hickox—who did not have Ebola and posed no risk to others—of her civil rights to quell fears of Ebola last fall. But now he’s saying that parents should be free to choose whether to immunize their children, even if that means putting others at risk. Paul, an ophthalmologist, should be telling us that measles is a leading cause of childhood blindness worldwide, but instead he’s perpetuating the myth that vaccines cause autism.
As a physician and a scientist, I believe that public health policy should always be rooted in the best available science. But I also acknowledge that our values influence our policy, including how we value a human life (our own, our children’s, others’), how we weigh different types of risk, and how we think resources should be allocated. So, public health policy will always be political. We as scientists must apply the same scientific rigor to our communication and advocacy efforts as we do to the study of medicine.
Dr. Celine Gounder is an internist, infectious diseases and public health specialist and medical journalist. All views expressed in this article are hers and should not be attributed to any of her employers.