The recent outbreaks of measles have caused a great divide within the ranks of parents with young children over vaccinations. There is an alarming trend in Pediatric offices toward strong-arming parents into vaccinating their children. Some offices are even giving parents who don’t vaccinate their marching orders to find a new Pediatrician. Those who know me will tell you that I’m a strong proponent of vaccinations, and I believe that vaccines are safe and effective. As a world medical traveler, I’ve had all of mine and then some, including the smallpox vaccine I got as a child.
However, I refuse to try and dictate to parents what they will or won’t do with vaccines. A pinch of caring and compassion I think will go further than a pound of forced “persuasion.” I will try to persuade parents through a good patient-physician relationship where they can trust that the vaccine information I present to them is sound and reasonable. I must, and will, however, put this decision in their hands as the parents of children that they love deeply.
No doubt much of the current rancor from vaccine-reluctant parents stemmed from the article published some thirteen or so years ago by Andrew Wakefield in the journal Lancet. His article stated that his research showed a direct relationship between the MMR vaccine and autism. Though the Lancet did recently refute these findings and retract his article, it took them more than a dozen years. The damage that the Lancet sought to correct had already been long done, and the MMR vaccine will probably forever be tainted by that article. As a result of his repudiated research, Andrew Wakefield now resides in the U.S. and no longer practices medicine at all.
The storm of anti-vaccine sentiments however continues. Those with children who are under a year or who cannot receive the MMR for health reasons are calling for ‘non-vaxxers’ to be forced to do so under the guise of public interest and safety. Those who refuse to vaccinate are holding to the rights they see as citizens to choose not to vaccinate. Underlying motives are difficult sometimes to ascertain on both sides. One thing I can say about mandates is that you only have to go so far as the current health care mandate mess to know what can happen. Once a mandate is in place, it is very hard to step back from it. A vaccination mandate would only add to more bad mandate decisions.
There are three groups of children that I think we need to consider here. The children in the first group are those who are ill and cannot receive the MMR vaccination because even an attenuated live virus vaccine poses a serious risk. Their parents want them to be able to attend school or daycare and try to live as normal a life as possible, free from the risk of infection with viruses like measles and such, wherever they go. The children in the second group are those whose parents are wary, even fearful, of the vaccines harming their children, and elect to refuse some or all of the vaccines, or opt for a different vaccine schedule than the current recommendations. The children in the third group are those whose parents are already planning to vaccinate per published recommendations, but the children have not yet been vaccinated for MMR.
Children in the first group who can’t receive vaccinations because of a medical condition are at risk everywhere in society unfortunately. As much as I would like, we cannot protect them everywhere they go. All large public venues are a danger to these medically immuno-incompetent children. I suspect that some 50,000 people a day may pass through many of WalMart’s 24-hour facilities. I tell my parents that I generally consider everything in such large, well-travelled places to be contaminated. I counsel the parents of my immunocompromised patients to be very careful about where they take their children.
Children in the second group, who may receive only a few or no vaccines, are at risk of getting the infections when they are exposed to others who bring in the infections across our borders, or when they travel beyond our borders. Unlike Yellow Fever, where visitors to endemic countries must be vaccinated prior to travel, and who must also present a Yellow Fever vaccination certificate before regaining entry back into the United States, we have no such screening for any other contagious infections. Even Ebola screenings, where death rates are upwards of 70 percent or more, are not properly done before a person reenters from an endemic Ebola area. Simply measuring a temple temperature is not good enough to make any clinical decisions by non-medically qualified airport personnel. I don’t trust these types of devices to make sound medical decisions in my office, and I’m an experienced physician. It has been shown, even among highly intelligent physicians and other healthcare professionals, that self-quarantine does not work either. Physicians and nurses are no better than anyone else who would try to circumvent heath prevention measures at our border. They act as though these barriers are good for everyone else, but do not apply to them.
Children in the third group are those who are in the process of being vaccinated according to schedule but are not yet immunocompetent. With respect to the MMR vaccination and measles, these children, however, are at risk for a period of up to the first year, where they have limited or no immunity. The MMR is not routinely given until on or after the first birthday. This is because the seroconversion rate, which is the measure of vaccine effectiveness, after the one year measles vaccination is around 95 percent or better.
While the solution for the first group lies in exposure prevention on a day to day basis, and for the second group in convincing parents to vaccinate, there is something more I think we can do to help the third group. It may also help to limit the exposure of immuncompromised children more effectively than trying to simply mandate that all children receive the present schedule of vaccines. Children can get the MMR vaccine before their first birthday. They will still be required to get vaccinated according to the regular two-dose schedule at and beyond age one year. It has been demonstrated that 74 percent of children who get MMR vaccine at 6 months do seroconvert and become immune to measles. Over 89 percent of those vaccinated at 8 months have been shown to acquire measles immunity. At 15 months the conversion rate is reportedly 100 percent.
It is already recommended that unvaccinated children as young as 6 months get the MMR prior to travel to endemic areas of the world or during local outbreaks of measles. I am now recommending to parents of my patients that they consider giving their children their first MMR at age 6 months. Currently, here in Georgia, these children will still have to have two more MMRs at or beyond their first birthday for daycares, schools and such that require a completed Georgia form 3231 vaccine certificate for attendance. This will, I think, significantly reduce the susceptible population of young children. It will also indirectly reduce some of the risks to the first group of children who are immunocompromised.
What about immunity to measles in the first 6 months of life then? Because the largest antibody transfer from mother to child occurs at some point prior to delivery, I’m recommending that all women who have low measles, mumps, or rubella titers, have their measles titers measured. If their titers are low, then they should be vaccinated prior to pregnancy. Prenatal transfer of the maternal measles antibody from seropositive mothers to their newborn children can give immunity that may last perhaps up to 4 months of age. Breast feeding does also transfer some maternal antibodies, but I don’t think that the quantitative effect is really known, and it probably cannot be relied upon to provide the protection we want.
Pregnant women or those planning to soon get pregnant within 28 days should first discuss MMR vaccination with their obstetrician. The CDC recommendations against live virus MMR vaccination during pregnancy are also based, according to the AAP Redbook, on theoretical risks of infection to the unborn baby. Women have been unknowingly vaccinated during pregnancy without negative effects to the fetus. Women thinking about becoming pregnant or who are pregnant need to discuss MMR titers and the indications for vaccination with their obstetrician. Determining pre-pregnancy measles titers are a very good idea.
This policy should help to significantly narrow the susceptibility of a significant number of healthy vaccinated children down to about two months. It will indirectly help reduce the risk to immunocompromised children. I will continue to encourage and educate my parents who refuse or want to delay vaccines why I recommend the current vaccine schedule for all children. The problem with forcing these parents to vaccinate seems politically driven rather than well-reasoned. Mandatory vaccination will certainly not stop the entry of measles into our country across the border which seems to be how the virus is getting here. Until we demand verification of an approved MMR vaccination by all citizens and non-citizens coming through customs, and until we fully control illegal entry at our borders, we will continue to be at risk for measles. Mandatory vaccination will gain nothing but the control of one group of people over another. It will further limit the shrinking freedoms for which we as Americans have fought and died.
Those interested in MMR vaccination before the first birthday should call their health care professional’s office and discuss all the particulars of insurance coverage, risks, etc. More information about the current MMR recommendations and the supporting sources for my information are found at PubMed.gov, the CDC’s Morbidity and Mortality Weekly Report, the CDC’s Measles, Mumps, and Rubella (MMR) Vaccine Safety Studiesand the CDC’s Vaccines and Immunizations page on the measles vaccination. I have written a free iTunes ebook for my parents called “The Pediatric Guide for Parents” which has extensive information on the various diseases vaccines protect against and lots of pictures. It may be helpful to parents who remain unconvinced.