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Vaccine Debate Reignites

Monday May 19, 2008
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Early this year, a 7-year-old boy traveled to Switzerland with his family and returned to his home in San Diego with an unwanted souvenir — measles. The boy had not been vaccinated, nor had nine of 11 other children and infants who caught the illness from him. This scenario has been repeated several times across the country in recent months. As of April 25, 64 measles cases had been reported, more for the time period than any year since 2001, according to the U.S. Centers for Disease Control and Prevention (CDC).

Most cases occurred in people who had never been vaccinated, and this, along with reports of a small, but growing, number of parents who choose not to vaccinate because of religious or personal concerns, has public health officials worried.

In the U.S., more than 90% of children are vaccinated, which makes a large outbreak of measles or other vaccine-preventable diseases highly unlikely, says vaccine researcher Louis Z. Cooper, MD, a past president of the American Academy of Pediatrics and a member of the steering committee for the National Network of Immunization Information. But health officials fear clusters of unvaccinated children could lead to an increase in local outbreaks. Some counties in the Pacific Northwest have reported exemption rates as high as 15% to 18%.

The increasing number of vaccine exemptions, along with conflicting information about vaccines available on the Internet, make it imperative for nurses, nurse practitioners (NPs) and pediatricians to engage in frank, open communication with parents who have concerns about vaccines, Cooper says.

“There’s enough noise and enough trend that it says to me we’d better take a look at the factors that are causing this and do something about it,” Cooper says. “This is a wake-up call.”

A 2005 survey of parents who chose not to vaccinate conducted by researchers at the Johns Hopkins Bloomberg School of Public Health showed nearly 70% believed vaccines cause harm. A 2002 survey by several nursing organizations found 75% of more than 1,000 parents surveyed said they would like to decrease the number of vaccinations their children receive at each visit, though they overwhelmingly recognized the value of immunizations.

Though vaccines are safe, they are not risk-proof. Reactions can range from mild fever and soreness to seizures and joint pain. Serious allergic reactions to vaccines are uncommon, according to the CDC. Other reported reactions, including brain damage and hearing loss, occur so rarely there is not enough evidence to show vaccines cause them, according to the CDC. But they do occur. “It’s the denial that bothers people,” says Cathleen Macrelli, RN, a med/surg nurse at Lahey Clinic in Burlington, Mass.

Macrelli spent years fighting for government acknowledgement that her 18-month-old son, David, died of a seizure caused by a reaction to a whole-cell pertussis vaccine in 1996. Studies of the vaccine linked it to a number of side effects, including an increased risk of febrile seizures — about six to nine per 100,000 children, according to a New England Journal of Medicine report. It has since been replaced by the safer acellular pertussis vaccine.

No one mentioned those reactions to Macrelli, she says. Had she known, she still would have had David vaccinated, she says. “But I would have felt after he died that, well, they did tell me this was a possibility. There are ways of presenting risk without scaring people.”

She advocates better reporting of vaccine reactions through the Vaccine Adverse Events Reporting System (VAERS), which does not require healthcare providers to establish a cause between a reaction and the vaccine.

Though many research organizations have found no link between vaccines and autism, a recent case involving Hannah Poling, a 9-year-old girl with autism, has raised new questions about the issue. Health officials conceded a febrile reaction to a series of vaccines may have aggravated a mitochondrial disorder that may have led to Poling’s autism. The U.S. Health Resources and Services Administration (HRSA) has denied the finding means vaccines cause autism.

But the case brings up the possibility that although vaccines are safe for the majority of children, there may be children with underlying immune conditions who could be more susceptible to vaccine reactions. Developing a way to identify those children should be a research priority, says Margaret Dunkle, Poling’s aunt and a senior fellow at the Center for Health Services Research and Policy at George Washington University and director of Los Angeles County’s Early Identification and Intervention Collaborative. “It may be that some kids should be vaccinated differently, for example later, less, or on a different schedule,” she says.

The son of Vicky Debold, RN, PhD, a patient safety consultant and researcher, who serves as a consumer representative on the FDA’s vaccine advisory committee, had a bad reaction after a measles-mumps-rubella vaccine when he was 15 months old. Soon, he was unable to stand, and he later stopped speaking. He was diagnosed with autism spectrum disorder before he turned 3.

Debold believes that until science and screening techniques provide more information about which children are more likely to develop adverse events, parents should have some input about how their children are vaccinated. “If something goes wrong, that parent is going to end up with a very sick child for the rest of their lives,” she says. “We have to support educating parents so they can make the best decisions possible.”

Before vaccinating, nurses should ask whether the child has had previous reactions to vaccines, she says, and whether there is a child with neurological and immunological disorders in the family. Nurses also should know what constitutes a moderate or severe reaction — seizures, fever, excessive somnolence, hypotonic-hyporesponsive episodes (collapse reaction), and screaming — and report these to VAERS, she says. In certain cases, she says, providers should support a parent’s decision to delay vaccines or at least offer to give them separately.
But delaying a vaccine may put a child at risk for a vaccine-preventable illness, and parents need to know that, says Patricia Stinchfield, RN, MS, CPNP, director of Pediatric Infectious Disease/Immunology and Infection Control at Children’s Hospitals and Clinics of Minnesota, and the first nurse to be appointed to the CDC’s Advisory Committee on Immunization Practice.

Stinchfield recommends providers listen to parents’ concerns. Some may have religious objections to pork products in some vaccines, she says. Others may know someone who had a bad reaction to a vaccine or may have read something that made them question vaccines. Pediatric nurses and NPs can address those fears, she says, by finding a vaccine that doesn’t contain pork products or referring parents to reputable websites that show vaccines’ effectiveness. Stinchfield does not believe there is any good scientific reason for spreading out vaccinations. However, she has spread vaccinations out when parents expressed strong concerns about giving many shots at once. “I think that if anything good comes out of the [publicity from the Hannah Poling case], it is that people are asking critical questions about vaccine safety,” Stinchfield says.

Many parents and practitioners don’t remember or weren’t born when illnesses such as measles or even Haemophilus influenzae type b (Hib) caused deadly complications in children, says Vicki Brinsko, RN, CIC, infection control coordinator at Vanderbilt University Medical Center in Nashville, Tenn. She recalls seeing children sick with meningitis from Hib, which was the most common cause of meningitis in young children until a vaccine was approved in 1987. “I haven’t reported a case [of Hib] in over a decade,” Brinsko says.

Providers need to be able to explain to parents why the risks of vaccination reactions are almost always worth taking. “Any infectious disease is one plane-ride away,” Brinsko says. “It’s like a slow leak. Now we can see the bottom of the boat and want to stop bailing, but the water starts to come back in.”

Visit the following websites for more information on vaccines and the controversy surrounding them.

http://www.cdc.gov/vaccines/pubs/providers-guide-parents-questioning-vacc.htm
The Centers for Disease Control and Prevention’s guide for providers when parents question vaccinations

http://www.hhs.gov/nvpo/
The National Vaccine Program Office of the US Department of Health and Human Services

http://www.immunizationinfo.org/
National Network for Immunization Information

http://www.hrsa.gov/vaccinecompensation/
National Vaccine Injury Compensation Program

http://vaers.hhs.gov/
The Vaccine Adverse Event Reporting System

http://www.cispimmunize.org/pro/pdf/RefusaltoVaccinate_revised%204-11-06.pdf
From the American Academy of Pediatricians’ Childhood Immunization and Support Program (CISP)

http://www.chop.edu/consumer/jsp/microsite/microsite.jsp?id=75918&mid=79368
The Vaccine Education Center at the Children’s Hospital of Philadelphia

http://www.immunize.org/reports/
The Immunization Action Coalition

http://www.nvic.org/About.htm
The National Vaccine Information Center

http://www.safeminds.org/
Sensible Action For Ending Mercury-Induced Neurological Disorders

News reports

http://www.cnn.com/2008/HEALTH/conditions/03/24/autism.vaccines/index.html
Part of a CNN series on autism about legal battles over claims that certain vaccines are linked to the condition.

New York Times
http://www.nytimes.com/2008/03/02/nyregion/nyregionspecial2/02Rvaccine.html?_r=2&pagewanted=1&oref=slogin
“More Families are Shunning Innoculations
http://www.nytimes.com/2008/03/21/us/21vaccine.html
“Public Health Risks Seen as Parents Reject Vaccines”

Gaining Parents' Trust

According to nurses who represent various sides of the vaccine controversy, pediatric nurses and nurse practitioners can take several steps:

• Give clear information about the risks and benefits of vaccinating or not vaccinating. Provide parents with printed information about vaccines before giving the shots. Let them read it over and ask if they have questions. Refer them to reliable websites that list risks and benefits.
• Take time to listen to concerns about vaccines. Find out if objections are based on religion, suspicion, or fear, and if possible, offer options that might address those concerns (for instance an alternative to a vaccine that contains pork products).
• Ask about reactions to previous vaccines. If a child had a moderate or severe reaction in the past, proceed with caution.
• When giving vaccines, pay close attention. As with any other medication, it is possible to give the wrong vaccine or the wrong dose.
• Report any adverse event through the Vaccine Adverse Event Reporting System (VAERS system) whether or not you think it was caused by a vaccine. The documentation is important in tracing possible vaccine reactions and making vaccines safer. Making the report also tells parents you take their concerns seriously.



Cathryn Domrose is a staff writer for Nursing Spectrum/NurseWeek.To comment, e-mail editorNTL@gannetthg.com.