I suppose it is best to start with the bottom line. Both of my children are immunized with the traditional schedule.
What I want more than anything from this blog entry is to illustrate my view on vaccines for children in a calm and collected manner. Truthfully, I hate talking about vaccines. It used to be different. When I was a medical student in Houston at the turn of the millennium, I was most drawn to pediatrics because of vaccines. Preventative medicine, early intervention, anticipatory guidance, and preventing life threatening diseases with science and technology- this is the bread and butter of a general pediatrician and I was enthusiastic.
In 1998 an article was published by The Lancet by Andrew Wakefield. I remember reading this my first year of medical school in our problem based learning small group. I remember a charming rheumatologist who was one of the cool younger teaching physicians moderating this session. He said “Listen up guys, people are going to ask you about this so let’s take a good look at this article and this study and see what we think, is this good science?” Of course, upon our critical appraisal the answer was a unanimous “no”. I believe we read 2-3 other studies in which the authors had tried to replicate Wakefield’s results and were unable to do so. I do not think that my medical school or that rheumatologist had any motive other than to teach us to critically appraise scientific studies. Anyhow, the point being, I remember reading the article and thinking “this is bogus and anyone can see that” and moving forward with my life.
Of course in medical school we learned about how immunizations worked and we saw the first rotavirus vaccine be taken off the market. The DTP vaccine had been redesigned to DTaP so that the side effects would be less severe. In my mind, the system was working, new vaccines were great but they would be rigorously studied and monitored and if there was any suggestion that the risks outweighed the benefits they would be removed, remodeled, and improved upon.
I remember doing my preceptorship with a private practice pediatrician. She told me that she told her prenatal interviewers that if they did not want their child to be immunized that she would not take them in her practice because “if we do not agree on that, we will not agree on anything.” I remember at that time being slightly in awe of her confidence but also quietly wondering if I would do the same.
As I went through my pediatric residency, vaccinations were not a topic of any debate. Of course not. You would take care of a 6 week old that died in the PICU with pertussis. You would go to your continuity clinic with a largely immigrant population that would not uncommonly ask you to repeat all the vaccines because they had lost their immunization card. They were grateful for the vaccines, I was never asked once if they were safe, if there were too many, or if they could be spaced out. The questions were usually how many vaccines can a child get in one day, in one thigh? How soon can they come back for more? I loved these questions, loved the charts, creating a catch up schedule. If there was ever a case conference of a child who had died of Haemophilous influenza, or strep pneumoniae meningitis, sepsis- the hands would shoot up in the air, could this have been prevented? Was it one of the vaccine serotypes? Was the child fully immunized?
I worked my first year out of residency at a high school based clinic in Oakland, California. The HPV vaccine was available and the “one less” campaign was a huge success in California. We had a type of insurance that was available to all people of child bearing age so we could enroll the high school kids, get their consent and give them the three dose HPV series for free. It felt like a miracle. I could see them, test them for STDs, treat the ones they had, and give them a vaccine to prevent cervical cancer. For historical sake, this was also the year after that the new rotavirus vaccine came out and I remember sitting down with the infectious disease doctors as a third year pediatric resident and reviewing all the safety trials and concluding that yes, this vaccine seemed to be an improvement on the previous and safe. I think my most overwhelming feeling was that “yay, its oral so the babies will not have an additional needle stick”. This was also the year Jenny McCarthy was on Oprah talking about “mommy instincts”.
I came back to Texas and worked at the medical school as a junior faculty member overseeing residents and medical students in the largely Medicaid clinic and inpatient wards at the children’s hospital. I remember a family admitted to our service with a MRSA (methicillin resistant staph aureus ) bone infection. They had insurance but they did not have a pediatrician, they were unimmunized, and they were lovely. The mom had delivered her 10 lb baby without medication and breastfed him for almost 2 years. They were smart, they had good questions, and they were great parents. As soon as the medical student took the history and found out that they were unimmunized it became the child’s main descriptor. “This is a 2 year old male, unimmunized, here with MRSA osteo day 4 of antibiotics” etc. I probed the medical student as to how that had any relevance to our current diagnosis, treatment, etc. I quickly became the devil’s advocate and remember specifically saying “she delivered a ten pound baby without medication- how can you possibly accuse her of not caring about her child?” I tried to recruit the family to our clinic, I told them that we would be their medical home and tried to pass it off to the resident as a good experience. She rolled her eyes at me. The family came once and never again to our clinic. During the same year we got a fax from the ER saying that another patient had presented with a generalized tonic clonic seizure. I knew that patient had just been in our clinic 2 days before and so I pulled up his chart to see what he had been there for, it was a well child check and he had received his vaccines. I asked the most experienced wonderful nurse at the clinic to grab a VAERS form (the vaccine adverse event reporting system). It was the first time that I had heard of a possible vaccine reaction in one of my patients and I knew that this was the proper thing to do. She looked me right in the eye and said she had no idea where to find one because she had never filed one before. Now, this struck me as entirely odd. The idea of any surveillance system is that you over report and how had this nurse with YEARS of experience never seen an adverse reaction, or worse, never been asked to report it.
Two years later, I had my beautiful baby girl. I had done everything within my power to do everything right by her. She never slept on her stomach, she never had anything other than breastmilk. I was following all the recommendations, even if it meant rarely sleeping. When it came time for her first set of vaccines I knew that I would have to do the traditional schedule. What kind of doctor was I if I did not practice what I preached? Why would the traditional schedule be okay for all my patients but not for my daughter? However, I remember looking at her perfect 13 lb body and reading the litany of rare side effects and feeling queasy.
Of course, 105 degree fever was rare, allergic reaction 1 in a million but what if your child was the one in a million that had anaphylaxis and died? I felt nauseated, I signed the consent and I nursed my baby right after and apologized to her profusely. She did fine. Even last year while getting her flu shot (because yes, I do get flu shots too) she smiled and said “that was a good shot!” She is fearless and luckily has done well.
When I decided to start my own practice, I read the Vaccine Book by Robert Sears. I believed potential clients would ask me what I thought about it. This book was regarded as blasphemous in academia, but I could not find anyone who had actually read it. I read it. And I liked it. I learned so much and I thought it was quite balanced. The alternative schedule is not so alternative and if it provides a middle ground for people who would otherwise not immunize their children, why not? I thought back to the family on the wards, they might have been open to the alternative schedule and could we not all agree that partial immunization would have been better than being completely unimmunized? In my last weeks at our clinic, a second year resident came out of a room fuming. He said, “can you believe that these parent’s thought that vaccines came from an aborted fetus? How ridiculous!” I shook my head and corrected him and we went back in the room to talk with the family about the cell lines from 2 aborted fetuses nearly 50 years ago and the Catholic church’s response and permission to get immunized. I didn’t blame the resident, I did not know of this until I had looked into concerns of the anti-vaccine advocates. But I do think that it illustrates the lack of knowledge some physicians have towards these concerns.
So, what do I tell my clients? I am respectful of any well thought out plan regarding the health of their child. One mother said to me “I mean, I am ultimately the one who will live with the decisions of what I decide to give or withhold from my child, and I clearly have the most to lose”. That really meant a lot to me and somehow shifted the way I thought of our relationship. I was a consultant to the parents who would ultimately make their decisions regarding their child. I am also respectful of any religious beliefs that may weigh in on vaccine use. I try to encourage the “on the fencers” to send me the articles that have them concerned. I cannot argue with the Internet at large. When someone says to me “But I heard that the CDC is filled with people who work for the pharmaceutical companies” I cannot argue with that, I do not know that to be true and I hope to high heaven that there is no truth in that but I do not know for sure. I wouldn’t even know where to begin to find that out. But when a client sends me a terrifying publication from 1980s about DTP, I can reassure them that the article is 30+ years old and talking about the previous version of the vaccine.
I help the families do anything they want that helps them feel better and more confident about their choice to immunize their child. If they want to do one vaccine at a visit while nursing their baby after 30 minutes of lidocaine numbing cream so be it! I do not charge for vaccine visits, I do not charge for storage, handling, or administration of vaccines. If anything, I lose a little money on them and I am okay with that. I do not ever desire to be in the position where I make money off vaccines and could be accused of being biased in my recommendation. And of course, my situation is entirely unique in that I have a tiny client base and do not have to deal with insurance companies.
I believe that vaccines are a good thing and that we should all do our part as citizens to get immunized and protect ourselves and more importantly, the most vulnerable in our community, even if there is a risk that we might suffer rare side effects. However, I do not believe that all vaccines must be given in clusters without any variation. Even the CDC traditional schedule has 4-12 week period recommendations for most vaccines.
But lastly, I sure wish that the AAP and CDC would find another spokesperson for vaccines than Paul Offit. I do not think he is evil but I do think that as a creator of a vaccine and therefore someone who financially benefitted from his vaccine being included in the traditional schedule, he is not an unbiased professional. It is standard procedure when critically appraising any research to review the financial disclosures and it seems that everyone has just decided to overlook this in his case.