Is Mandatory Vaccination Destroying An Important Bond?
By Red Flags Columnist, F. Edward Yazbak, MD, FAAP
An article by human rights journalist Anai Rhoads Ford entitled “Why signing a waiver to avoid vaccines can be considered abuse” was recently circulated to parents’ groups in the United States. (1) Originally written in the fall of 2005, it says, “Recently, The Washington Post printed an article (2) about vaccine waivers that could jeopardize your parental rights. In the article was the following comment: "The American Academy of Pediatrics recommends that doctors ask parents who refuse to vaccinate their children to sign a waiver indicating they are aware of the risks of refusal."
The article went on “Know Your Rights … By endorsing this particular waiver, parents would essentially be signing an admission of neglect and/or ‘abuse’ for refusing vaccines. The language contained in this waiver could put parents and caregivers in jeopardy later if they should ever find themselves in the courts due to their child’s health problems, when confronted with child protective services, divorce, or just about any matter pertaining to their child that could be used against the parent(s). Please read any waiver provided by your child’s doctor, daycare or school carefully before signing. Instead, offer a formally written and signed letter that simply states that you do not wish to vaccinate your child. If you are unsure of the language in the waiver, buy some time by telling your doctor or the school that you need to consult with a lawyer before signing it.”
As a Fellow of the American Academy of Pediatrics (AAP) since 1963, I was obviously disturbed. We had just driven another wedge between our patients and us and further compromised our previous superb rapport and mutual respect: We were asking parents to sign a potentially incriminating document that quite possibly could be legally challenged.
I accessed the AAP web site and found a letter to parents by our new president Eileen M. Ouellette, MD, JD, FAAP, (3) which says in part: “At its peak before measles vaccine became available, there were more than 494,000 cases of measles in one year. Measles killed 3,000 children and resulted in 48,000 hospitalizations annually. In 2002, thanks to immunizations, there were 44 cases of measles reported in the U.S.
“Most parents, and many grandparents, have no personal experience of seeing children suffer from these severe childhood illnesses: diphtheria, whooping cough, polio, mumps, chickenpox and H. flu meningitis. Consequently, they may not appreciate the seriousness of these diseases or wrongly believe they no longer exist.
“It is vital that we continue to immunize our children against these preventable diseases or else they will return. Each of these diseases, after all, is just a plane ride away.
“Unfortunately, there is much misinformation about vaccines, some of it on the Internet. We are pleased to provide you with accurate information about immunizations and encourage you to discuss any questions you may have with your pediatrician.”
I thought the President’s letter was kind and most appropriate — as I expected it to be. I have not met her, but she is eminently qualified to lead us in these difficult times and I certainly wish her all the best. Although I believe, as she does, that we need to vaccinate children and adults, I find the timing and number of vaccines and combination vaccines outrageous and outright dangerous. I totally agree that parents should discuss their children’s vaccinations with their pediatricians, but I also think that they should get the other side of the story and make informed decisions. If pediatricians cannot consistently convince parents to vaccinate their little ones, then maybe they, too, should review the whole subject with an open mind. They could learn something that the vaccine lobby has chosen not to publicize.
Although immunization and vaccination are one and the same by definition and are often used interchangeably, I prefer the term vaccination. The substance that we inject into a baby is a vaccine. It does result most often in immunity but such immunity is neither guaranteed nor always long lasting. In addition, vaccination may cause complications that could be more serious than the disease it is supposed to prevent.
Deciding that a vaccination is needed, useful and appropriate at a given time is a serious matter. A vaccination decision may be the most important a parent will make. “I wish I could turn the clock back” is a sentence I have heard quite often, unfortunately. One thing is certain: No one can aspirate an already injected vaccine. This is why informed vaccination decisions are so crucial.
In her letter to patients, Ouellette describes how sick she was at the age of 8 when she developed measles. I was 24 when I contracted measles and exposed my older sister. I was not very sick but my poor sister almost died from complications of the disease. Three years later, as a resident in an infectious disease hospital, I took care of a young mother who had measles encephalitis and spent hours and hours watching over her. Thank God, she made a remarkable recovery. I wheeled her to her station wagon on one beautiful sunny day and had tears in my eyes when her five little children screamed with joy: They had not seen Mom in several days. At the time, children were not allowed in hospitals to visit. The husband, a big man, was also sobbing when he gave me a big bear hug and tried to say “th ... tha … thank you, doc.” I have a lump in my throat remembering that day.
Although I am fully aware of the many complications reported following vaccination, I certainly believe that appropriate vaccination against measles is needed. It is evidently also effective: A 2005 UNICEF report describes a decrease of almost 40 percent in cases of measles worldwide since 1999. (4)
The statistics provided to Ouellette and quoted by her were actually conservative as to the yearly number of cases of measles in the United States before the introduction of the monovalent vaccine in 1963. We had, according to the Center for Disease Control and Prevention (CDC), 894,134 cases of measles in 1941, 799,455 cases in 1934, and 763,094 in 1958.
On the other hand, because of better hygiene and nutrition, the yearly mortality from measles had decreased precipitously decades before the vaccine was developed. We have had less than 3,000 deaths per year since 1938, when we had 3,296 measles-related deaths in all age groups. We have had under 1,000 deaths from measles per year after 1946, and below 500 yearly deaths after 1958.
The following table demonstrates the change in the epidemiology of measles and deaths from measles with improved health conditions and before the introduction of the vaccine.
Year 1913
Population - 97227000
No. Cases - 203690
Attack rate/100000 - 209.499
Deaths - 7446
Death rate/100000 - 7.658
Death-to-cases ratio x100 - 3.656
Year 1960
Population - 179323000
No. Cases - 441703
Attack rate/100000 - 246.317
Deaths - 380
Death rate/100000 - 0.212
Death-to-cases ratio x100 - 0.086
It should be noted that while the number of cases of measles and the attack rate were remarkably higher in 1960, the number of measles-related deaths, the death rate and the death-to-cases ratio were all substantially lower that year than in 1913. (Source: CDC)
Much has been made — unfortunately — of a small study from Chicago by Erin A. Flanagan-Klygis, MD, et al, entitled “Dismissing the family who refuses vaccines: a study of pediatrician attitudes,” which was published in the October 2005 issue of Archives of Pediatrics & Adolescent Medicine. (5) The study results were discussed in the press, on television and on the Internet.
Flanagan-Klygis wrote, "Responses to our survey suggest that some pediatricians, faced with vaccine refusal, may seek to end their relationships with refusing families, citing a breakdown in trust, fear of litigation, or lack of common commitment to 'standard' medical care for children."
The important word in that paragraph is “may” — as in, may seek to end their relationship. The study did not report incidents of actual patients’ discharge.
The cited arguments are also ludicrous: The fact that parents do not trust vaccines and their makers certainly does not mean that they do not trust their pediatricians. In addition, there cannot be any threat of litigation if the doctor clearly documents that, in spite of his urging and careful explanation, the parent or guardian refused to sign the permit allowing the administration of the vaccine.
As to lack of commitment to standard medical care, who are we to tell parents that the CDC’s Advisory Committee on Immunization Practices (ACIP) is infallible and more committed to the welfare and health of their children than they are. To date, no one has succeeded in convincing me that administering a vaccine that is not needed to a newborn or giving seven or eight vaccines together to a two-month-old baby meets any reasonable standard of good medical care.
It certainly hurts our ego when a parent disagrees with us and refuses a vaccination, but a bruised ego does not need life-long treatment or special education and rehabilitation. We do get over it. Unfortunately, the babies may not fare as well if they are part of the small minority that develops a serious complication. I was heartbroken in 1997, when a young mother asked me not to give her newborn the hepatitis B vaccine. I told her that it was not blood-based anymore, that I read a lot about it, that it was safe and that I had administered it to all my grandchildren. And she said, “I have never disobeyed you before, but I really do not want this particular vaccine for my baby right now. I do not have the disease and he is not at risk.” I obviously respected her wishes. If she ever reads this, let me assure her that I am now in total agreement with her. She was right!
The membership of the AAP exceeds 60,000 pediatricians. Flanagan-Klygis mailed her survey questions to 1,004 of them; 302 responses were analyzed.
I am obviously aware that in superbly designed studies, results of such a small sample can be reliable and safely projected. But this was not a full-protocol study; this was only a mail survey. Not being one of the lucky 1,004, I do not know how the questions were phrased. I am confident, nevertheless, that the same questions stated differently can provoke different responses. In any case, the responses (and the study) expressed the recollections and interpretations of less than 0.5 percent of the AAP membership.
Some 54 percent of the survey respondents had encountered a parent who had turned down all vaccines, and 256 of the 302 (85 percent) pediatricians had families with partial vaccine refusal within the previous 12 months. Seventy three percent of the physicians surveyed attributed the parents’ refusal to safety concerns and 22 percent said that the parents were concerned about the administration of multiple vaccines — all together.
Eighty two respondents (less than one-third) said they would ask the family to leave their practice if the parents refused specific vaccines, and 116 said they would probably ask complete vaccine refusers to transfer to other physicians.
The survey also examined the attitude of the pediatricians about vaccinations.
An overwhelming majority (85 to 96 percent) stated that DTaP (diphtheria, tetanus and acellular pertussis), HIB (Haemophilus influenzae type B), MMR (measles, mumps and rubella) and IPV (inactivated poliovirus) vaccines were extremely important.
About a third of the pediatricians surveyed ranked the hepatitis B vaccine, the chickenpox vaccine (Varivax) and the seven-valent pneumococcal conjugate vaccine (Prevnar) as somewhat important.
Prevnar, hepatitis B, Varivax and IPV vaccines were also judged optional by a small percentage of responding pediatricians (4.6, 2.3, 6.6, and 0.99, respectively).
The results of the survey raised questions:
- Were the pediatricians who were surveyed really considering discharging infants and children from their practices just because their parents had safety concerns?
- Were they actually going to discharge patients or were they just voicing their frustration to someone/anyone who was willing to listen?
- Were the responses reactions to the questions or to actual practice situations?
It is important to note that the AAP Committee on Bioethics has stated: "Continued refusal after adequate discussion should be respected unless the child is put at significant risk of serious harm (as, for example, might be the case during an epidemic). Only then should state agencies be involved to override parental discretion on the basis of medical neglect. Physician concerns about liability should be addressed by good documentation of the discussion of the benefits of immunization and the risks associated with remaining unimmunized.”
According to the CDC, the immunization provider plays a key role in helping to ensure the safety and efficacy of vaccines through proper:
- Vaccine storage and handling
- Vaccine administration
- Timing and spacing of vaccine doses
- Observation of precautions and contraindications
- Management of vaccine side effects
- Reporting of suspected side effects
- Communication about vaccine benefits and risks
Though mentioned last, proper communication with parents or patients is extremely important.
The CDC recommends (verbatim):
Communicate about vaccine benefits and risks
Before you administer each dose of certain vaccines, you are required by law to provide a copy of the most current Vaccine Information Statement (VIS) to either the adult vaccinee or to the child’s parent/legal guardian…
Be prepared to manage vaccine side effects
… Severe side effects, such as severe allergic reactions following vaccination are extremely rare. However, any provider who administers vaccines should have procedures in place for the emergency care of a person who experiences an anaphylactic reaction ...
Report suspected side effects to VAERS
The Vaccine Adverse Event Reporting System (VAERS) is a national vaccine safety monitoring program. VAERS collects information about adverse events (possible side effects) that occur after administration of U.S. licensed vaccines. The National Childhood Vaccine Injury Act requires healthcare providers to report selected events occurring after vaccination to VAERS. However, VAERS encourages reporting of any clinically significant adverse event that occurs after administration of any vaccine licensed in the United States, even if it is not certain that the vaccine caused the event … (6)
Because it would be totally counter-productive, the AAP and the CDC do not recommend discharging infants and children because their parents wish to decline or delay certain vaccinations. It is only by keeping the children coming back and by continuing to care for them that we can hope to convince the parents to allow judicious vaccination.
If I were still practicing pediatrics, I certainly would not ask parents to transfer out of my practice because they wish to delay or omit a vaccination. I would simply write a detailed note on the chart and give the parents time to think things over.
If the families that are discharged from pediatric practices do not find a “sympathetic” pediatrician, they may choose to see health professionals who do not believe in any vaccination or forgo pediatric care altogether. In that case, it would be us, the pediatricians, who would have failed to meet the standard of good medical care.
General practitioners and internists would not dare discharge a patient if he or she refuses a vaccine or wishes to delay it a year or two. I can just imagine a family physician telling a lawyer in his practice: “Go find another doctor. How dare you not obey me? I know everything about health and you do not. I want to give you a booster and you dare refuse. I want you to leave my practice.”
At the end of my last check-up, my doctor asked me if I wanted a flu shot. “We have plenty of vaccine this year,” he said. My surprised face quickly brought him back to reality. “I guess not,” he added gently. “I’ll see you in six months.”
Recently, a dear friend accompanied his wife to a prenatal visit where she declined the influenza vaccination that is now recommended in all trimesters of pregnancy. The obstetrician was not too happy but he did not “fire the patient” — possibly because the husband was also a physician and eminently more informed about influenza vaccination during pregnancy. The following Monday, my friend called to ask the obstetrician a question. He was not in. He was having a reaction to his flu shot.
I do not believe that our first and only function as pediatricians is to administer vaccines. If it were, then we would not need four years of college, four years of medical school and three years of pediatric residency (at least). We would only need to take an evening course on vaccine administration.
Periodic health examinations are very important by themselves. We need to monitor growth and development, look for abnormal findings or new pathology, follow up on existing problems and discuss diet and safety measures. We must simply advise and assist any way we can. We should encourage reasonable vaccination practices, answer questions and — above all — show that we care. If we ask a parent to leave our practice, we are missing all that and forgetting that this is still a free country.
Waivers can only compromise the rapport between doctors and patients, They should not be used and the Academy should review the subject, as soon as possible.
One can only imagine the office space and the personnel that will be needed if we had to use waivers for every situation where the patient or the parent refuses to do what we recommend.
We could actually run out of colors if we decided to color-code them:
Too many Twinkies: Blue waiver
Too much soda: Green waiver
Pregnant at 15: Purple
Refusing to wear condoms: Yellow
Still smoking: Red
I happen to think that it is more important to discover a heart murmur and to stress that a one-year-old boy must be well strapped in a good car seat than to give him the rubella vaccine.
I also think that I am better off spending time convincing a teenager to drive safely, to always use a seat belt and to avoid smoking, drinking, drugs, unprotected sex and proximity to firearms than to fly in and out of the examining room and send my nurse in with the new whooping cough booster.
Lately, the rapport between pediatricians and parents has suffered much, for a multitude of reasons. The flood of mandated and recommended vaccinations may have been one.
It is our duty to do everything we can to stop any further erosion of such an important bond. Reason must prevail.
Copyright ©2006 RedFlagsDaily.com
About the Author: Dr. Yazbak, a pediatrician, now devotes his time to the research of autoimmune regressive autism and vaccine injury. (tlautstudy@aol.com)
This article was originally posted on RedFlagsDaily.com on 05 April 2006.
References:
1. Rhoads Ford, Anai. Why signing a waiver to avoid vaccines can be considered abuse. AnaiRhoads.org, 15 November 2005.
2. Sandra G. Boodman. “Feuding Over Vaccines.” Washington Post. Nov. 8, 2005.
3. Letter from AAP President.
4. Measles deaths plummet. UNICEF 3/4/2005
5. Flanagan-Klygis EA, Sharp L, Frader JE. Dismissing the family who refuses vaccines: a study of pediatrician attitudes. Arch Pediatr Adolesc Med. 2005 Oct;159(10):929-34. PMID: 16203937
6. Vaccine Safety: The Providers Role. CDC, National Immunization Program.
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