Sunday, September 20, 2015

Leadership and Vaccines: From Presidential Candidates to American Families

I watched the Republican Presidential Candidates Debate on CNN Wednesday night (September 16th) and noted when the vaccine fuse was lit by asking Donald Trump about how he would relate to the CDC on the issue of vaccines.  I knew his response would light up Twitter, the CDC, Public Health professionals and 99% of Primary Care Pediatricians.  He answered like a concerned first time parent dressed up in a Donald Trump costume with a Donald Trump attitude.  He said they stretched out the immunizations for his children and "it worked out".  He referenced the child of one of his employees who had a horrible reaction to an immunization.  Ben Carson, MD showed his Neurosurgeon stripes by responding meekly on the subject and generally agreeing that there are too many injections and they might be spaced differently.  Rand Paul, MD (Ophthalmologist) expressed his support of vaccines AND, on the other hand, his love of freedom (of choice on immunizations).  It was polite commentary.  The medical community response wasn't.

I reviewed a few Twitter streams and blogs which spewed anger and disparaging comments about Mr. Trump primarily.  The name calling and insults were aimed also at the Republican Party. Evidenced-Based civility was lacking.

Vaccine discussions seem to melt into name calling, in general, after one or two shared comments - all over the internet.  One group attests to the safety of immunizations, strongly implying that there are no studies stating otherwise.  The other group attests to the dangers of vaccines and the harm that many children have suffered from one immunization or another.  Passion abounds.  They all care deeply.  They are doing the best they can based on what they believe.
Candidates Guide
I appreciate Chad Hayes, MD - the pediatrician who wrote "The Presidential Candidates Guide to Vaccines".  Notice the 114 comments including the types I mention above.

These comments cover the opposing opinions pretty well.  The world of either/or covers a lot of territory.  The gray world, where the Family Physician and individual Families often live can be more challenging and confusing.
Have vaccines saved lives?  Yes. They are safe for most persons and helpful for our entire society.
Did anyone ever have a reaction to a vaccine that resulted in permanent injury?  Yes.  Death?  Yes (everything we prescribe has the potential to have a fatal reaction, but with vaccines, it's extremely rare.) But we're not supposed to let you read such a comment because it may cloud your judgement.
Other problems from vaccines?  Look at VAERS, the government site where physicians report serious reactions to immunizations:   Serious reactions from date of injection

We know that the percentage of serious reactions is tiny compared to those with the usual reactions like local pain, fussiness, fever, etc.  And tiny compared with the benefits for individuals and society as a whole.

Is there some information in the CDC site that we should hide from you?  Should we be like the old time GP who kept the secrets and just "had to be trusted"?  Are many parents angry about not knowing about the VAERS or the huge amount of information about vaccines and vaccine preventable diseases on the CDC web site?

A lot of medical practice revolves around the concept of "normal".  What is normal?  From Ian McWhinney's A Textbook of Family Medicine:
"To identify individuals at high risk requires an understanding of the meaning of normal.  In the history of medicine, few errors have led to so much harm as the failure to be precise about the meaning of the term.  Although present when the physician is assessing and treating illness, the risk of harm is especially great in preventive medicine, for here the physician is identifying abnormalities in patients who have not come for treatment of symptoms or who have come with symptoms that bear no relation to the identified abnormality.  Identification of the abnormality may then lead to treatment that has risks and costs.  At the very least the patient will have an anxiety he or she did not have before.
To think clearly about normality, the physician must have an appreciation of human variability.... individual variation (and)...variation between individuals,...partly genetic but also partly the result of adaptation of individuals to different environments."

So when recommending immunizations, individual variability should be considered.  Who is at risk for what?  What is the context of their current health situation?  What might be their genetic predispositions relative to vaccine preventable diseases?  What sensitivities might they have to specific vaccines?  Is the CDC recommended schedule right for them?  Do they need a consideration for an adjustment to the usual schedule?  Look at the schedule for infants, adolescents and adults and note the variations for persons with chronic conditions, etc. Immunization Schedules

These are simple and complex schedules.  Vaccines are a complex issue and decisions about vaccine preventable diseases are complex.  It is a challenge for parents to be informed about the diseases and the vaccines.  The CDC web site is informative and overwhelming, but important.  The information form about each immunization is both summarized and deep depending on where you look in the site.
CDC Vaccines

Your physician is also very helpful, but short on time for in depth teaching about immunizations. Families generally have to work together whenever there is a new infant in the home.  Later immunizations require updates about vaccines to make the most informed decisions.

I believe that each individual family will have to make their own informed decisions about vaccines. We Family Physicians can provide a lot of information and show them the recommended and required (for Ohio schools) vaccines and they have to make what they consider to be their best decision.  Parents have many sources of information and should be able to consider the context of their child's life and theirs as they think of all the ways that vaccines may help.  They will also think of ways they may be harmful.
Enter the Principles of Medical Ethics:
1.  Respect for Persons/Autonomy: Acknowledge a person’s right to make choices, to hold views, and to take actions based on personal values and beliefs
2.  Justice: Treat others equitably, distribute benefits/burdens fairly.
3.  Nonmaleficence (do no harm): Obligation not to inflict harm intentionally; In medical ethics, the physician’s guiding maxim is “First, do no harm.”
4.  Beneficence (do good): Provide benefits to persons and contribute to their welfare. Refers to an action done for the benefit of others.

These considerations should be continuously in the mind of the physician.  Yes- the patient has the right to make choices about immunizations.  For several years most parents in my practice opted not to get the chicken pox immunization, assuming their child could get it like they did- from an infected friend or classmate, until they realized that no one seemed to get the chicken pox anymore.  Times change.

Some parents opt for no immunizations or to delay until the child is an age to be determined (two seems to be the age they pick).  About five families in my practice were "fired" by pediatricians for refusing one or all immunizations.  Four of them were shocked at the anger/ rage of the pediatrician at their desire to alter the immunization schedule for their infant (including having no immunizations)  I believe they own their children and they have an obligation to make informed decisions relative to their health, in the context of their lives (including their community).  Objections to them having the freedom to choose are well argued in the comments to the Presidential Candidate Guide above.

A tiny group of individuals and families are genetically predisposed to have adverse reactions to certain immunizations.  The PBS special about immunizations mentioned one such mutation.  Many families with autism are concerned about methylation mutations such as MTHFR or BH4 or CBS mutations leading to vaccine reactions in some.  Our Human Genome Project was supposed to give us more tools to discern those risks, but those options are not at the front line yet.  With IT and EMR's they are closer.

I love immunizations.  They have saved lives.  I enjoy gray, too.  Each patient is uniquely one of a kind.  Their biological variability is important and worthy of consideration, curiosity and respect, as are their values, goals and dreams.  Knowing and honoring that is the essence of being a Family Physician.

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