With vaccines…Is there no middle ground, no room for questions?

“We should be as demanding of ourselves as we are of those who challenge us.”

Dr. Jerome Groopman, writing in the New Rupublic

Writing about the medical decision-making surrounding vaccines proved to be sketchy. Yesterday’s post brought stinging criticism from both sides of the debate. A pediatrician felt the structure of the post was patronizing. Just an hour later, a skeptic sent me the same message–patronizing. This was educational.

Criticism is taken seriously here, especially when it comes from both sides of an argument. The reflex: Perhaps its useful to write more on the matter? (It’s funny; writing that sentence caused me to think about my childhood. My younger brother and I would often find ourselves in conflict with our parents. My reaction was always to argue, explain and make the case. My brother never did this; he simply ducked quietly into the weeds, a master of inflammation avoidance.) True to my childhood self, then, here is a reach for clarity.

First is the question of why a cardiologist would insert himself into the vaccine debate? It’s not your fight. Butt out.

Medical decision-making: Vaccines, as therapeutic interventions performed in well people, highlight the issue of patient-centered decision-making. My field, cardiology, is currently undergoing a major transformation in this area. The pivoting involves a culture shift, from one of paternalism to one of shared-decision making. It’s been a remarkable thing to witness. Cardiologists are learning that in science and medicine, the rule is uncertainty. The goalposts move. Look no further than the new cholesterol guidelines. For decades, we were certain that lowering cholesterol was better. So sure was the establishment that cholesterol lowering was made a quality measure. Good doctors had patients with low numbers. Now look: the new guidelines completely upend that idea. Living through these sorts of medical reversals, learning from history, celebrating uncertainty and striving to improve communication is why medical decision-making intrigues me.

I believe this is the golden era of communication in medicine. In the previous generation, doctoring involved mastering one or two approaches to a problem. Take this or you will die. Now, with the vast array of treatment choices, the challenge is much more about helping patients navigate the expanded menu. It’s a good problem to have, having more available treatments that is, but it presents a different challenge. Humans are complicated. We come with different perspectives of risk, different goals of care, different incentives and different views of science even.

Vaccine Creep: One critic noted my failure to mention vaccine creep. In adult medicine, a common problem is poly-pharmacy. Each individual drug may be reasonably safe and effective for its intended disease. But given together, with 5 or 6 or more other chemicals, there are likely to be important interactions. This week, for instance, the NY Times covered a study that persuasively suggested muscle side effects from statin drugs may be related to drug interactions.

So it’s reasonable, at least in my multiply-concussed radiation-exposed head, to consider the aggregate effects of the increasing number of vaccinations given to babies. Are we totally satisfied that aggressive modulation of the immune system in healthy children has no significant risks? We can just keep adding vaccines? The more the better? I’m just wondering out loud. Is it heresy to even have the thought that early and massive infant vaccination will some day look like ear tubes? Less is more in almost every other aspect of medicine, just not in infectious disease?

The ice is really cracking now. I should turn back. But let’s not; let’s chance it and go further:

Hep B vaccine in babies? I have yet to hear a convincing reason to mandate vaccinating a newborn for Hepatitis B–a blood/body fluid transmissible disease. (I looked through 6 pages of a Google search. It yielded recommendations, associations and speculations.) It’s not because we think 5-year-olds will be exchanging body fluids on a bloody sports field, is it? It’s not for convenience or adherence. Because surely we aren’t saying that we think parents can’t be relied on to bring their older children in for a beneficial treatment. No misunderstandings please. I’m not suggesting Hep B vaccine is dangerous or that it is a bad idea–I am glad I am protected–but is it wrong to question the net clinical benefit of giving Hep B vaccine to a newborn who lives in non-endemic suburbia and was born to an HBV-negative mom? I’m just asking. Maybe someone has a convincing scientific explanation; it’s just not on the first 6 pages of Google.

Caregiver fatigue: Here, I should have been more understanding. Cognitive doctoring is difficult. I come home after office days completely and utterly drained. It’s exhausting to repeatedly explain that good sleep, good food, good exercise and good attitudes crush any medicine or procedure–even those advertised on the evening news. Even more tiring is the attempt to convince Americans that they don’t need procedures or pills or roll-on hormones. Pacemakers are easy to implant; convincing someone they don’t need one. That’s another matter.

Another problem is that curiosity and skepticism make office work much harder. When I was less skeptical–when I unquestionably followed expert guidelines, for these are the experts after all–office days were more productive and less exhausting. “Yep, you need that cholesterol drug, no question about that.”

I strongly believe a solution to the caregiver fatigue problem is to approach it like the Finns approach education. One of the reasons Finland has a superior education system is that they value teaching. Right now, in the US, we don’t value the teaching aspect of doctoring. That needs to change–even though it would lower my salary.

Right of self-determination: Finally there is the issue of individual freedom and mandate overreach. Are we a country that will tolerate mandated medical interventions? I think not. Forbes journalist Mathew Herper writes extensively (and expertly) on the Merck HPV vaccine Guardasil. In this post, he makes the argument that aggressive efforts to mandate the Merck vaccine–just 2 years after the Vioxx debacle–caused a backlash against a safe way to prevent some forms of cancer. After reading his post, I can’t help but wonder whether a gentler less authoritative approach would have resulted in more widespread acceptance of Guardasil. I guess the question is: how much protection can doctors expect to mandate in a country that doesn’t meaningfully limit guns or tobacco sales?

Now I’ll get back to cardiology.

JMM

Comments

  1. says

    THANK YOU John. I for one am GLAD that you do not simply stick to Cardiology. I too felt criticism yesterday from some of my comments. I am fully aware of the concept of “herd immunity” – so for certain vaccines for certain conditions it is not uniformly appropriate to allow full patient autonomy because that may endanger others. But that is not a concept that extends to all vaccines (ie, vaccination to protect against Herpes Zoster). Vaccines have provided tremendous benefit over the years – they are generally safe and generally effective – but to fully accept all recommendations without question given a far-less-than-perfect record by our regulatory agencies and potential conflict from the big bucks to be made? I think the questions need to be asked. I think there is room to slow down the rapidity with which children receive their immunization schedule (witness the difficulty we had trying to figure out which of the 8 or so immunizations from a single day caused the reaction in our grandchild). NOTE: Not “stop” – but “slow down” – that is, work with patients/families – and also acknowledge when there are gray areas. THANKS again for not sticking only with cardiology John!

  2. Doctorsh says

    Dr. John

    How many infections with HepB are prevented by mandating HepB vaccine?
    Do we know what the nnt is for the vaccine?

    How many heart attacks are prevented using statins?
    We do know the nnt for statins in primary prevention, and it is not great.

    Interesting which nnt would be better and would that info change the debate?

  3. says

    Hello Dr. M. – I too am always happy whenever you veer away from All Things Cardiac. Please keep it up.

    While I strongly support early childhood vaccination programs (one only has to watch the gruesomely painful videos of toddlers suffering with whooping cough to be permanently moved), I find myself on the horns of a dilemma.

    At my friendly neighbourhood pharmacy, I have my prescription for Zostavax, the shingles vaccine, waiting for me. It’s been waiting there for five months. I can’t seem to make myself pick up the phone and book an appointment (pharmacists here can administer vaccines).

    My family doctor prescribed this for me after a lengthy bout of shared decision-making conversation in her office that ultimately helped to convince me. But between that visit and booking the actual appointment with my pharmacist, I became less and less convinced.

    For one thing, as a heart patient who takes a fistful of cardiac meds every single day, I have no clue which of these were prescribed for me based on tainted clinical trials or flawed journal articles. And worse, neither do my docs.

    What I’ve learned in the five years since my MI about the pharmaceutical industry’s pervasive influence on the practice of medicine is frightening: selective outcome reporting of drug trials, drug recalls, data mining, publication bias, “file drawer effect”, medical ghostwriting, illegal kickbacks to medical “thought leaders”, record-setting multi-billion dollar legal settlements against Pharma, and the rise of “marketing-based medicine”.

    Frankly, I don’t trust drug ads to help me decide on anything anymore, nor, sadly, do I trust the opinions of docs educated by their drug reps.

    Merck’s massive ad campaign for Zostavax lays out its marketing hook in bold: “Have you had your shingles vaccine yet?” My educated, intelligent middle-aged friends are frightened by this and so they have ALL had their shingles vaccines already, while wondering why I am dragging my feet – me of all people, who lives, breathes and sleeps women’s health issues. Then I read Alan Cassels piece on this topic (he’s a well-respected and independent drug policy analyst here at the University of Victoria) – http://commonground.ca/2012/08/shingles-vaccine-stats-misleading/ – and his perspective on the actual data behind the Herpes Zoster vaccine further delayed my decision and prolonged my confusion.

    I suspect it’s about fear. We have to be more afraid of the consequences of NOT getting any given vaccine than we are about the vaccine itself. But it’s also about a much worse fear: that we no longer know who we can trust.

    And that is truly frightening.

    • Jeff says

      Excellent points, all. Zostavax doesn’t even come near the hoped for 90+% effectiveness. If you do get shingles, however, it will probably be a milder case.

      It’s a question of balance. Balance your fears: Google shingle images!

  4. says

    I need to write my shingles story. Yes, I had shingles. The pain from my many deceleration injuries merge together, not one much more or less memorable than the other. Shingles is different. I will never forget that experience. Oh my. #suffering.

  5. Jack says

    Jeez, if you’re looking for totally save meds, and , you don’t seem to trust anyone ( particularly unethical folks like me who work in device & Pharma – & will subject our families & friends & ourselves to these poisons) don’t take anything. Get shingles. Or, maybe you could go get 8-15 years of post HS education,,and figure it out yourselve — since those docs & Pharma reps are clearly not ethical and in it for the money.
    Conflicted ? I suggest a support group.
    Or, move to Portland — the land of anti vaccinations and real time studies on what happens ,when you go “holistic / organic “.
    Curious : name of insurance carrier in your province ???
    Seriously, get the shot. Listen to your doc & friends . Shingles is not good.
    Jack

    • says

      Dear Jack – I refer you back to the title of this post, “With Vaccines – Is there no middle ground? – Is there no room for questions?” The issue of vaccines simply isn’t an “all or none” phenomenon. I am one of those you refer to who went and got 12 years of post HS education, followed by a 32-year career as a practicing physician. It simply isn’t “all or none” as your defensive reply implies. There needs to be room for questions – and in certain aspects, there should be SDM (Shared Decision-Making). Tell me the fee for Zostavax isn’t exhorbitant? (not everyone will be covered for this vaccine – as per Carolyn Thomas reply above). For some folks – Zostavax is a great offer; For others – the relatively low chance of Zoster is not enough to balance the cost. In any such decision-making process – N= 1, which means that IF you are one of the unlucky ones to come down with Shingles and you didn’t get vaccinated – then you made the “wrong” decision. But if you didn’t get vaccinated and don’t get Shingles, then you made the “right” decision. Shouldn’t the patient who is paying the ~ $200 out-of-pocket have the right to decide?

      NOTE – I am NOT saying infants and young children should not be vaccinated – but I am saying that there should be room to allow a spacing out of such vaccinations such that concerned parents can reduce the number of immunizations given in a single visit – which allows: i) an opportunity to see how their child handles vaccines; and ii) an opportunity to figure out WHICH vaccine was the “culprit” in the event of an adverse reaction. To pretend that anyone has all of the answers is fantasy.

      • Rob Cordes, DO says

        I believe you raise a good point if a child receives 8 vaccines and has an adverse reaction which one was it? That is probably the case in many adverse reactions. If a patent with CAD is on polyp pharm which is causing the reaction?
        Fortunately significant adverse reactions to vaccines are rare and localized reactions can be deduced by site given and components ex “D” in 4th and 5th DTaP are more likely to cause local reaction than others. Live attenuated vaccines cause a more delayed 7-14 day system reaction than inactivated vaccines.
        The problems with spacing and delaying vaccines are
        -delayed time until one is immune
        -increase overall stress – giving 4 vaccines in one visit is less stressful than 4 over 4 visits
        - time , expense and travel risk with multiple visits.

      • says

        Rob – I totally understand all in your answer. Yours is the “logical” (if not paternalistic answer) – and I totally get that the number of antigenic particles given in current vaccines is way less than ever before when fewer vaccines were given. Yours is the answer I’d give in years past when I wore my “doctor’s hat”. But the “delay” until one is immune is not necessarily a clinically relevant factor (we are not talking about waiting for years … ) – a mother knows better than the doctor as to whether 4 vaccines in one visit is “more stressful” for her child than 2 vaccines over 2 visits – and the patient is the one who is paying the extra expense of making an extra visit. From the “other side” – you’d be AMAZED at the difference it makes allowing option to parent of spacing out vaccines a little bit (and in a child not yet exposed to other children when spacing isn’t excessive, it really doesn’t matter clinically that “immunity” is delayed by a small amount).

      • Rob Cordes, DO says

        Thanks I will gladly accept being logical.
        No intention on my part of being parenternalistic but as I think about it don’t we often have to be? Intentionally or not and even as much as we want patients / parents to engage in decision making.

        I’ll will grant rare cases of needing to space vaccines briefly. Ex a 6 month old on day 3 of amoxicillin gets multiple vaccines then hives shortly afterwards.

        The evidence shows increasing the number of vaccines does not increase infant stress. Do you have evidence parents can tell it is more stressful on the child?
        It is more stressful on the parents watching than it is on the infant getting the vaccines.
        I suspect I am kicking a hornets nest but I doubt parents can tell an increased stress from multiple vaccines especially when the science says otherwise.
        There is a lot of parental anxiety and observer bias involved.

        Unnecessarily delaying vaccines is conter to the standard of care and sub standard medicine. The disease we protect against are baby killers.
        Seventy five percent of young infants with pertussis get it from their immediate family.

    • jane says

      Jack – I’m far from impressed with the amount of ad hominem in your comment. The essay linked above noted that annual incidence of shingles in older-middle-age people was 1 to 2 per thousand and that, from a large clinical trial of older people at much higher risk than that (or than I am), ca. $30,000 had to be spent on vaccines per shingles case prevented. In most cases, shingles lasts only a few weeks. I know Americans are supposed to be totally intolerant of (natural) suffering, but as a person of modest income, I would gladly take a few weeks of pain in exchange for a gain or a prevented loss of $30,000 (not counting emdee visits, or for many, missed work). If you want to convince me that my values are wrong, you’ll need more than insinuations that I’m less educated than you or mentally defective and in need of a “support group.”

  6. Jeff says

    Dr John,

    Lisa Murakami and Robert Ellis address the question of newborn hepatitis B in “Vaccination, A Layperson’s Perspective”, cited in your previous post. Look at comments from September 28 at 8:04 PM to October 2 at 11:28 AM
    (She sure was busy!)

  7. Jack says

    IMHO, we need basic health education at the HS level. Meaning: what is a real study? ; beware of aspects of Internet ‘education’ ; good resources; risk assessment; your personal responibility ;
    your societal responsibility ; costs ; insurance …… It is very difficult to educate & answer questions when even the well educated ( ie: masters in social work, English ….etc.) don’t remember basic math, or, can’t read a study conclusion, or , expect 100% safety .
    We did some research on how docs educate patients . We ,first, researched the actual patients (and,family members) ; then, the RN’s, and finally ,the physicians.
    Findings : MD’s,generally , felt they were very good and putting time and effort into patient ed ; however– patients said they had real problems with their doc’s ‘outputs’,,,liked their nurse education and, most of the time ,family members were not included ( key conditions when family education is needed). Are many doctors deluded ? Or, simply unable to deal with the pile of internet research Mrs.Jones brings in at each visit. Finally, time is a real issue — it needs to be compensated & alternate ed paths need to be used ,ala, cyber tutorials that patients must view.
    CT : wait til doc does genome ‘set’ on you and RX’s per your specific needs. Conflicted ?? Indeed .
    Sorry for another rant,but, I’m amazed at the fundamental worrying ,when citizens (over past 70 years) are living longer,better and happier though the advancements of medical science. Why the increase in anxiety ? New issues are : ? Too long, how to pay , 100+ year life spans. Good blog & discussion thread , thank you.
    Have a wonderful and healthily Holiday!
    jack

  8. Rob Cordes, DO says

    John,

    I’ll add another vote for you not sticking with just cardiology!

    Some answers to your questions,
    As for number of early childhood vaccines we give less totoal vaccine than we did years ago while immunizing against more diseases
    The current pediatric immunization schedule will give a child 150-160 antigens over the first year. Compare this to the previously given small pox vaccine (approx 200 antigens) or whole cell pertussis ( approx 3000 antigens). http://pediatrics.aappublications.org/content/109/1/124.full.pdf+html
    Also consider than our immune system much on an everyday basis mount a defense against the millions ( or is it billions) of bacteria that colonize or skin, respiratory and GI tracts. Vaccines are a drop in the ocean compared to this.

    With Hep B vaccine trying to target high risk groups was not effective.
    From : http://www.immunize.org/askexperts/experts_hepb.asp

    Administration of a birth dose of hepatitis B vaccine is standard operating procedure (SOP) and is required for effective postexposure immunoprophylaxis to prevent perinatal HBV infection. Although infants who require postexposure immunoprophylaxis should be identified by maternal HBsAg testing, administering a birth dose to infants, even without HBIG, serves as a “safety net” to prevent perinatal infection among infants born to HBsAg-positive mothers who are not identified, because of errors in maternal HBsAg testing or failure in reporting of test results.

    “The birth dose provides early protection to infants at risk for infection after the perinatal period. Although infections in young children represented less than 10% of all HBV infections before implementation of routine childhood hepatitis B vaccination, childhood infections resulted in an estimated 30% to 40% of the chronic HBV infections among people who acquired their infections in the United States. Many of these chronic infections would not have been prevented by a selective program of identification and immunization of only infants born to HBsAg-positive mothers.”

    As for NTT, interesting question but my patents await……I will get back on that one.
    Rob

  9. says

    Could someone please define NTT? I’m not finding anything on Google that looks like it would fit into this context. I’ve ruled out “nearly total thyroidectomy” as a possibility, but am currently stumped. Thanks!
    Also, why is the shingles vaccine so expensive? Is there a business plan to break even on development costs before the current group of people who did have chicken pox die off? Just wondering. I got the shot, had a significant local skin reaction, but am glad I did. It’s a terrible thing to have happen to you.

    • Rob Cordes, DO says

      please see my post below
      BTW I just clicked on your name and saw your blog – a mistake to do on a 40 degree rainy day in Pennsylvania

  10. Rob Cordes, DO says

    Allison
    NTT = “number needed to treat” or should it be NNT to NNTT?
    anyway the number of people or doses needed to prevent 1 case of disease.
    Ex have to give x doses of Hep B vaccine to prevent 1 case of Hep B or 1 case of liver cancer secondary to Hep B etc.

  11. Jack says

    Dr.C – thanks for comments & info.
    Dr.G- also, thanks. My “defensiveness” had more to do with the declared facts that the companies , us scientists, product managers,clinical study protocol designers,,,etc.,,etc. ,according to some on this blog are just into our careers for profit (really bad word, huh). Not with standing , we live and breath our careers with these patients/family members. So, I apologize for the misplaced rhetoric , on my part. Thin skin syndrome .
    As far as HPV , shingles,,,etc. My position has more to do with the “required” baby/toddler vaccinations and the parents who put so many in serious harms way. These patients should not be allowed in clinics . They should pay higher premiums . They should be heard culpable for affected patients . These parents must be responsible for their children ,as well as , societal health issues they may cause ! With your experience , you must know how research has been effected by the Wolf criers . Almost nobody is investing in new “leap frog” innovations. The FDA is at almost all time low levels of “class I” level disruptive technologies / Pharma /devices. You benefited , in your career ,by the robust advancements of hundreds of significant drug/devices/imaging/diagnostics. We are in a much different era – sad.
    Good dialogue ; debate.
    Thxs to Dr. J for the platform . I just wish more could reach the lay info pathways & new education initiatives be explored.
    And who said they are cold with 40*F. Here in Minnesota – we have – 6*F ,tonight,,,,- 10-20 F windchill. Help !
    With kind regards and respect,
    jack

  12. Rob Cordes, DO says

    I wish I knew how to reply with quotes but anyway…..

    “Are we totally satisfied that aggressive modulation of the immune system in healthy children has no significant risks? We can just keep adding vaccines? The more the better? I’m just wondering out loud. Is it heresy to even have the thought that early and massive infant vaccination will some day look like ear tubes? Less is more in almost every other aspect of medicine, just not in infectious disease?”

    OK it is infectious disease but it is also preventative medicine. Is less more in preventive medicine?

    Dr John asked regarding Hep B vaccine for low risk babies:
    “I’m just asking. Maybe someone has a convincing scientific explanation; it’s just not on the first 6 pages of Google.”
    Hopefully my first post answered that but I did try a google search “Google” and “Google Scholar” using the search phrase “Rationale for infant Hepatitis B vaccine United States” and got numerous immediate hits.
    Maybe your problem was in the search phrase as mine might be searching “cardio protective effects of lifestyle modification vs statins” – not getting nothing relevant (sorry do not mean to digress…)

    Sorry I have not been able to find a number needed to treat on Hep B vaccine so I did punt that one to the vaccine experts.
    A usual email is nipinfo@cdc.gov
    Members of the National Immunization Program answer those questions and if you want a government agency that dose its job I have rarely waited more than an hour for a reply. Anyone can email them.

    Vaccines are somewhat different from other pharmaceuticals as the company rep does not ask to come into my office to promote use of their product in anyway not consistent with CDC recommendations. Sure a company might want to promote their brand of Tdap or HPV vaccine but the reps for meningococcal vaccine do not come in and say “The CDC recommends routine use at 11 years old but the FDA has approved it for infants so you should give it to infants. ”

    The push for mandating HPV vaccine was in my opinion a mistake.
    I am in favor of an anti cancer vaccine but people do not contact HPV by sitting in school next to someone else with HPV. It is not airborne.

    John, maybe you should get back to cardiology a little gradually such as your next question / post being “How many children need to be immunized against influenza or pneumococcus to prevent one adult case with cardiac complications.
    Kids are germ factories. Cute lovable but germ factories.

  13. says

    I wanted to follow up on NNT = Number Needed to Treat – esp. re how it applies to Zostavax (as discussed in some of the above comments). Perhaps the most prominent name regarding the concept of NNT has been Dr. David Newman, key mover in the web site referred to in an above comment re cholesterol (the “NNT Group”).

    - The NNT Explained on that site – GO TO: http://www.thennt.com/thennt-explained/

    - List of topics reviewed by the NNT Group – GO TO: http://www.thennt.com/home-nnt/ – though I didn’t see Zostavax listed.

    A KEY concept is that IF the “NNT” for taking a medication to prevent a certain outcome is 50 – this means that 49 people end up taking the medication and get NO benefit – just so that the 50th person can get the benefit. N = 1, so if you are the 50th person – it was “worth it” – but it cost money, time, extra visits, etc to the other 49 people. Expressed in this manner – MANY of the potential interventions in medicine that have valid, data-derived relative “improvements” in outcome don’t sound so appealing any more – ergo the push for more SDM (shared decision-making).

    Realize that those pushing for use of the intervention express outcomes in terms of relative benefit (ie, there is a 20% improved outcome) – whereas in fact in absolute terms, the NNT might be high …

    I did find this excellent post on Zostavax – GO TO: http://www.sciencebasedmedicine.org/shingles-vaccine-zostavax-confirmed-safe/ – They cite an NNT over a 3 year period to prevent 1 case of Shingles = 58; and the NNT to prevent 1 case of PHN (= Post-Herpetic Neuralgia – which is what you REALLY want to prevent) = 364. While on the one hand – if everyone got vaccinated you might prevent 250,000 cases of Shingles in the U.S. each year (sounds like a lot!) – but on the other hand, it means 363 people would be vaccinated ($200 a shot) without having PHN prevented. So, 57 people have to be treated to prevent 1 case of Shingles (Zoster) – and 363 have to be treated to prevent 1 case of post-herpetic neuralgia.

    These numbers may be overestimates – as people living with children seem to be less susceptible to Zoster … So despite commercial adds on TV to the contrary – this isn’t an “open-and-shut” case (and it is being promoted by those with potential to make big bucks). This is NOT to say that you should NOT get Zostavax – but only to say that it is one example of where I believe informed decision-making is important. Unfortunately – physicians don’t get paid for full informed decision-making, and realistically there just are not enough hours in the day to conscientiously do this for every patient and still survive financially. This is the dilemma I believe Dr. John is writing about.

    P.S. I am NOT saying to use the above argument for pediatric vaccines.

    • says

      Thanks Ken. I use the NNT often, especially when discussing anticoagulation risks.

      The other notable feature of your excellent comment was the use of the word, ergo. I’ve been trying to work that one into a post for some time. Grin.

  14. says

    IN RESPONSE TO Dr. ROB CORDES’ COMMENT ABOVE: Rob I understand the passion in your logic and I truly appreciate your impressive knowledge base for book medicine in the subject area of vaccinations. That said – as one who has taught medical students and family medicine residents locally and nationally for over 30 years (as well as seeing my own panel of patients during this period) – I respectfully submit that you are in fact being overly paternalistic.

    It is true that sometimes we do need to be paternalistic (ie, “Doc, you decide for me”) but much (most) of the time I found this NOT to be the case if an attentive moment is spent with the patient truly listening with goal to understand their desires and value system.

    It is not an issue of “needing to space vaccines briefly”. IF the parent wants to space vaccines a little (NOT a lot!) because they are simply not comfortable giving multiple vaccines in one visit – and IF the parent IS reliable and agrees to bring the child back in short order for a vaccine that delaying a month or two will really make NO difference in long-term outcome – WHY is this a problem for you? I understand that it then becomes essential to ensure that the child is brought back for those vaccines that are slightly delayed – BUT there ARE reliable parents out there who WILL agree to bring their child back AND follow through with this.

    By asking “if I have evidence that parents can tell if an intervention is more or less stressful for their child” – you are gaining NO points with the parents of the children that you see. I know of many parents who would not continue seeing a physician who doesn’t believe that the parent is better than the physician at determining whether an intervention causes stress or not in their child. SORRY – I don’t have prospective randomized controlled trials to prove parents know their children better than the physician does.

    And even if there was “scientific evidence” that “proved” it was “not stressful” for the child to receive multiple vaccinations in a single visit – WHY is this a problem IF there really is NO difference in longterm outcome by delaying a vaccine for a month or two in a young child staying at home cared for round-the-clock by a loving, capable parent who is not yet introducing that child to multiple other children?

    What I describe is NOT “substandard medicine” as you say. On the contrary – what I describe increases the likelihood of adherence because there is shared decision-making by a collaborative team of caring parent and physician who listens.

    I respectfully offer the above as a counter view to your perspective. I am respectfully signing off on this thread, as I just don’t know how else to say the above. This is not an “all or none” issue. Sincerely – Ken

  15. Rob Cordes, DO says

    While Ken has respectfully signed off I will briefly respond.
    My main point is we have a safe effect immunization schedule based on science, evidence based medicine and expert opinion. Patients deserve the best and the standard of care.
    There is no evidence that delaying vaccines by a month or two is safe.

    Again Jon thanks for posting on the topic.

    Rob

  16. PGYx says

    I have repeatedly tested immune to Hepatitis B following vaccination 20 years ago, so I intend to decline the HBV vaccine for my newborn when the time comes. The immune system is not yet fully developed at birth, so in a definitely HBV-negative newborn, why not wait until the immune system can better benefit from the vaccine? S/he can get the vaccine as a pre-teen.

  17. RK says

    As a research toxicologist, I wade into these conversations with trepidation. Emotional reactions plow fertile ground for misrepresentation of bias.

    Bias is inherent and to deny as much is divorcing our realities. Despite our best efforts to remain ethically unbiased, funding sources affect our sphere of relational bias.

    That being said, I find it interesting the lack of education surrounding the immune system, genetics, organic (not granola, but naturally occurring immunities) due to individual circumstances (shared immunities, ie) rates of breastfeeding, exposures to environmental toxins relational to geography and epigenetics in relation to those toxins.

    As this only further complicates, patient mediated decision making, I suspect the knee-jerk reaction would be an increasing paternalistic approach of schedules and the pushing of NNT.

    However, I harken back to Dr. Johns’ comments regarding diabigatran and patient mediated adherence to compliance. I believe there will always be those patients that require a compliance “regime” due to their lack of personal responsibilty. And this will hold true for infant vaccinations as well.

    But as we move more towards a medical model utilizing individualized treatments based upon genetic modulations, I can’t help but postulate that genetic sequencing, albeit unrealistically prohibitive, may soon play more of a role in immune mediated responses.

  18. Rob Cordes, DO says

    Just to get back on the NNT
    It would be based on how contagious the particular disease is within the population and how the percent of people who need to be immune for herd immunity. So no easy answer.