Your questions answered: Pediatric vaccines

As a first-year pediatric resident, Brian Moore, DO, MPH, says he’s already seen the negative health outcomes children can face when their parents decide not to vaccinate them. This year, several children with severe influenza were admitted to the West Palm Beach, Florida, hospital where he works.

Although the flu vaccine wasn’t as effective this year, Dr. Moore says children he treated who had the vaccine recuperated faster than those who didn’t.

“What I’ve seen firsthand is that for patients who get vaccinated, the flu is a lot less severe and the recovery is a lot quicker,” says Dr. Moore, who serves on the AOA’s Bureau on Scientific Affairs and Public Health.

As a physician in training, Dr. Moore says he’s still forming opinions on various aspects of vaccination and learning best practices from his attending physicians. To assist him and other DOs and to recognize National Public Health Week (April 6-12), The DO posed common physician questions about vaccines to experts. Here are their answers.

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Should I ban unvaccinated child patients from my practice to protect children who are too young for vaccination?

Until a few years ago, pediatrician Jan Widerman, DO, treated unvaccinated children at his Philadelphia practice. However, reading a Pediatric Annals article written by Stan L. Block, MD, caused him to rethink his approach.

“Dr. Block wrote that patients who come to his office believe they are in a safe environment,” said Dr. Widerman. “If you have unimmunized children there, you can’t guarantee a safe environment.”

Dr. Widerman and Dr. Block aren’t alone: One-quarter of physicians surveyed in 2011 by the American Journal of Preventive Medicine reported dismissing patients for refusing vaccines.

Lisa Klatka, DO, acknowledges that pediatricians who dismiss unvaccinated patients have legitimate concerns. But Dr. Klatka, a preventive medicine officer with the U.S. Army, also sees several reasons for physicians to keep treating this patient group.

“Continuing a relationship with the parent allows the opportunity for that relationship to develop and for the physician to provide education and allay fears while underscoring the reasons behind the recommended vaccination schedule. Also, since recommended vaccinations start at birth, terminating the relationship with the patient and parent may mean the child does not receive other well-child visits and screenings,” Dr. Klatka notes, adding that her views are her own and don’t necessarily reflect the views of the Army or the Defense Department.

Dr. Klatka points out that parents sometimes change their attitudes about vaccination and when they do, physicians can implement a catch-up schedule to fully protect the child.

Susan Mackintosh, DO, MPH, the chair of the AOA’s Bureau on Scientific Affairs and Public Health, encourages physicians not to “fire” patients who won’t vaccinate their children.

“To turn these patients away is a lost opportunity for education,” says Dr. Mackintosh, who is also the associate dean for assessment at the Western University of Health Sciences College of Osteopathic Medicine of the Pacific in Pomona, California.

How should I advise parents who don’t want to vaccinate their children?

“No. 1, be proactive,” says pediatric infectious diseases specialist Michael Ryan, DO. “Let families know that you are a vaccinating pediatrician. Note on your website that you require patients to get vaccines.”

He advises pediatricians to seek a common goal with reluctant parents—to work together to find a vaccine the parents agree is important for their child to receive. To do this, Dr. Ryan painstakingly goes over every vaccine with the parents, and he’s found that the time-consuming endeavor frequently pays off.

“Somewhere in that list, we usually find some common ground where they go, ‘Oh, maybe we should get that,’ ” says Dr. Ryan, who practices with Geisinger Health System in Danville, Pennsylvania, and has spoken about immunization at several medical conferences. “It’s almost always tetanus. People realize that their kids are going to get scrapes and bumps. And tetanus is just an awful disease.”

Dr. Klatka takes a similar approach to working with vaccine-resistant parents.

“Most patients appreciate a collaborative relationship over an authoritarian one,” she notes. “Vaccination is just one of many behaviors that improve health, but influencing behavior change can be difficult. It can require time and patience. Addressing patients’ concerns with factual information in a nonjudgmental manner goes a long way.”

Physicians can also consider sharing with patients how they personally approached vaccinating their own families. “When parents know that the clinician is up to date on vaccines and vaccinates his or her own family, they often feel more comfortable vaccinating themselves or their children,” says Dr. Klatka.

A few of my patients have heard that some vaccines are derived from aborted fetal cell lines, and they are concerned. How should I advise them?

The viruses used to make most vaccines are grown in cell cultures, notes Dr. Klatka. For certain vaccines, namely rubella, chicken pox, and hepatitis A, the virus is grown in human cells.

“These cell lines were cultured from cells taken from two fetuses, both obtained from elective abortions in the 1960s,” Dr. Klatka says. “No new or additional fetal cells are utilized in the current production of these vaccines.”

Dr. Ryan says he is often asked about fetal tissue in vaccines when he gives talks on immunizations.

Usually, the concerned party isn’t aware that anti-abortion groups such as the Roman Catholic Church and the National Catholic Bioethics Center have stated that the benefits these vaccines offer women and children usually outweigh the concerns about their origins.

Informing parents of the Catholic statements may be enough to assuage their worries, but if not, physicians can suggest patients discuss the matter further with their spiritual advisor, Dr. Klatka suggests.

How can I make sure I recognize rare vaccine-preventable diseases like measles and whooping cough?

Dr. Moore, a pediatric resident, notes that most residents will likely remember that a facial rash and a bad cough are signs of measles and facial swelling could be mumps. Residents learned about these illnesses in medical school, so they still have the information fresh in their minds. .

Dr. Klatka also encourages physicians to refresh their knowledge about these illnesses.

“Since these diseases are so much more uncommon than in the pre-vaccine era, clinicians should familiarize themselves with case definitions,” she notes. “Criteria are frequently made available to practitioners from health departments, or they may be found in publications like the American Public Health Association’s Control of Communicable Diseases Manual.”

What should I do if a patient with measles or another highly contagious disease comes into my practice?

Health care professionals should immediately isolate a patient with suspected measles or another highly communicable disease and immediately inform their local or state health departments, according to Dr. Klatka. “In many cases, these conditions are reportable immediately by telephone, even when the diagnosis is only suspected,” she says.

To protect other patients, Dr. Ryan recommends booking unvaccinated patients and patients who might have measles at the end of the day or after hours when possible. Other steps physicians can take include seeing patients in a reserved exam room that’s not in regular rotation and bringing patients in through the back door.

“Sometimes these children are very sick, and you want to get them in as soon as possible,” Dr. Ryan says. “But a patient who coughs in your waiting room can aerosolize the virus, which might stay in your waiting room for hours. That’s why we try to see these children at the end of the day.”