COMMENTARY

To Vaccinate or Not: Calming Worried Parents

Arthur L. Caplan, PhD; Paul A. Offit, MD

Disclosures

April 10, 2014

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Close Up With Paul Offit

Arthur L. Caplan, PhD: Welcome to Close-Up With Art Caplan. I am very excited today to have as my guest Dr. Paul Offit, Head of Infectious Diseases at the Children's Hospital of Philadelphia. Thank you so much for coming.

Paul A. Offit, MD: Thank you, Art.

Dr. Caplan: It's fair to say that, in my view, Paul is the leading advocate and has done more for promoting vaccination than anybody else I know in the world. He has been a staunch advocate of helping kids receive necessary vaccines and has been a pioneer himself in vaccine research.

Calming a Parent's Vaccine Fears

Dr. Caplan: In your experience, what can be done to calm parents who are worried and hear such things as, "My child got sick after a vaccination"? Putting aside the lack of merit behind some of those fears, how do you calm a parent down?

Dr. Offit: A fear was raised originally in the late 1990s and early 2000s that vaccines caused autism. Fair enough. From the parent standpoint, my child was fine, he or she got a vaccine, and now my child is showing signs and symptoms consistent with autism. Could vaccines have done it?

The good news is that this is an answerable question. It has been answered in a scientific venue. Tens of millions of dollars have been spent by public health and academic professionals to try and answer this question: If you receive a vaccine, are you at greater risk for autism than if you don't receive a vaccine? Now we can comfortably say to parents that those 2 things are not causally associated. Vaccines don't cause autism.

Dr. Caplan: So we have a mountain of evidence?

Dr. Offit: Yes. The problem isn't that parents have the questions. It's fair that they have the questions. Nor is the problem that people haven't responded with millions of dollars to answer the question. They have answered the question. So, what now? Why, with all that information on hand, can't we convince people?

I don't think it's a lot of people, but some people simply have the fear, and it's hard to make the fear go away. In part, it is because we haven't identified a clear cause or causes for autism. We don't have a definitive cure for autism, so that keeps the fear running.

Consider diabetes in the 1800s, when people didn't know what caused it. There were many thoughts about what caused it, and many thoughts about what could cure it. When Banting and Best discovered insulin and we knew the cause of diabetes, and how to cure it, all of the myths disappeared. For something like autism, that may be what it's going to take.

Dr. Caplan: Do you think that it would help to say to a parent that there are suggestions that older parents are more likely to have a child with autism, or that environmental toxins might be associated with autism? I have seen these things explored as causes of autism. Would it calm their fears to say that there may be other factors that we are chasing besides vaccines as causes of autism?

Dr. Offit: You can certainly say that, with respect to environmental factors, vaccines are clearly the best studied, and many factors have been looked at in autism research that make sense and are confluent. Clearly, there is a genetic predisposition for autism. If you look at the proteins that those genes make -- the so-called developmental proteins -- they are often expressed in the first or early second trimester. Environmental factors, such as valproic acid, thalidomide, or rubella virus, increase the risk for autism because they affect the child in utero.

Eric Courchesne and colleagues[1] at the University of California, San Diego, showed that there are folding abnormalities in the brain. You can actually see the foldings in utero by looking at the child's brain, so it's all consistent.

When you have autism, you are born with autism. There is no changing that, and to some people, that is helpful to know.

Responding to "That's Too Many Vaccines"

Dr. Caplan: What about parents who are worried about their child receiving too many vaccines at once? How do we handle that concern?

Dr. Offit: I don't care how sophisticated you are about virology or microbiology or immunology -- when you watch your child lie down on that white paper and receive as many as 5 injections at once, it looks like it's too much.

When you are in the womb, you are in a sterile environment. When you enter the birth canal and the world, you are not, and very quickly there are trillions of bacteria on the surface of your body. I'm not trying to sound like Carl Sagan, but you have about 100,000 trillion (1014) bacteria on the surface of your body. You actually have more bacteria on the surface of your body than the number of cells in your body.

We have a way of carrying bacteria from one place to the next, and to which you make an immune response. Adults typically make as much as 5 g of secretory immunoglobulin A and immunoglobulin G daily to make sure that those bacteria stay at the mucosal surface.

One single bacterium out of the trillions of bacteria on your mucosal surfaces has between 2000 and 6000 immunologic components. If you add up all of the immunologic components in vaccines that are given in the first few years of life, it comes to about 160. It's literally a drop in the ocean of what you encounter and manage everyday, but you don't see that.

Dr. Caplan: When the parent comes in and says, "I'm worried about too many vaccines," and then goes home and lets the child crawl on the floor or lets the dog lick the child, is that worth pointing out to them? They are not exposed only to what is there naturally, but they are exposed to lots of agents in the ordinary course of wandering around the house.

Dr. Offit: And that is good, because it educates the immune system away from this Th2 response toward the so-called Th1 response. It makes you less likely to be allergic as you get older. That actually helps, but if people really want to scare themselves, they should take a cotton swab and swab the inside of the child's nose, put it on a wet-mount microscope slide, and look at it. If it's teeming with bacteria to which your child makes an immune response, that's a greater challenge than what you ever receive in a vaccine.

Dr. Caplan: So those metaphors could help.

Dr. Offit: I think so, yes.

A Lose/Lose Situation for Clinicians

Dr. Caplan: Here is another issue. Many doctors and nurses have had people come in and say, "I don't want to vaccinate." What can we do with them? Should we say, "Stop coming here," or should we try to work with them? Should we say, "We will stretch out the vaccine schedule"? What's your view about that?

Dr. Offit: I feel sorry for the private practicing clinician, my wife being one of them. It's a lose/lose situation. On the one hand, the doctor can say, "I'm going to do the best I can to give this child whatever vaccines I can," knowing that you are sending the child away less than fully vaccinated, and knowing that this is going to be a progressively more dangerous world where there is a greater incidence of measles, whooping cough, and bacterial meningitis.

Dr. Caplan: We have had outbreaks of all those diseases in the past year.

Dr. Offit: Now, you know you are practicing substandard care. You know you are putting the child at risk, and so it's hard for doctors. But on the other hand, they can say, "If I don't at least try and play it the parent's way, where does the person go then? Do they just go to a chiropractor who is perfectly willing to not vaccinate their children, or to another doctor who is willing to give them no vaccines?"

I have seen my wife progress through this, and she has gone 180° toward the opposite view. She is far more passionate. She says, "Let me love your child. Don't put me in a position where I have to practice substandard care. Don't put me in a position where I'm sending your child out into this world that is becoming progressively more dangerous, where they can get pneumococcal disease or varicella and suffer that. Don't put me in that position. It's like coming to me and saying, 'I love my child, but I don't trust car seats.'"

Dr. Caplan: I like that "let me love your child" angle. It makes an alliance with the parents. What about when a child who hasn't been vaccinated comes to the clinic? Do you say, "Don't mix with the other patients in the waiting room"?

Do Parents Have a Responsibility to Others?

Dr. Offit: That's a good question: Do you have a responsibility to the waiting room?

In the measles outbreak in San Diego that occurred a few years ago, that is exactly what happened. The mother didn't vaccinate her children, and she took her children to Switzerland. The 7-year-old got measles, came back, and was sitting in the waiting room. The mother didn't know what it was. She had never seen measles before.

The child had fever and a rash, and was exposing everybody else in the waiting room. Three of the children in the waiting room were less than 1 year of age and hadn't yet been vaccinated. All were severely infected with measles, were admitted to the hospital, and one almost died. The mother of the child who almost died said, "She made a decision for me." Did she have a right to make that decision?

Dr. Caplan: Ethically, it may be important to let people know you vaccinate not only to protect your own child, but also to protect your neighbor, and I don't think people understand that clearly. Sometimes it seems that it is all self-interest.

Dr. Offit: Do we have a responsibility to our neighbor? Is it our inalienable right to catch and transmit a potentially fatal infection? I would like to think that the answer is no.

Dr. Caplan: Pushing that a little further, there have been movements in several states -- Rhode Island, for example -- mandating flu vaccines for pre-kindergarten and daycare, saying that children can't go to these places unless they are vaccinated. I think it includes the teachers now as well. Is this a good idea? Should we push harder for that kind of requirement?

Dr. Offit: You are seeing what has happened. Before the 1970s, there were medical exemptions to vaccination, but no philosophical or religious exemptions. Those were established in the 1970s and 1980s, so now 41 states have religious exemptions, and 20 states have philosophical exemptions to vaccines.

Dr. Caplan: "Philosophical" just means "I don't like it."

Dr. Offit: I'm not sure. It never made much sense to me.

Dr. Caplan: As a philosopher, it seems to me it is a deep philosophical objection.

Dr. Offit: Philo means love, and sophia means wisdom. Where is the wisdom that says not getting a vaccine is better than getting one?

We are seeing the consequences of those exemptions. When we see such outbreaks as measles or whooping cough, invariably they are centered on groups of people who have chosen to not vaccinate their children. Not only do they serve as a reservoir for the children to become infected, but they infect members of the surrounding community, so now we are starting to see pushback. There was an article in JAMA Pediatrics[2] on this topic, and we are seeing legislation not for expanding those exemptions, but for contracting them.

Dr. Caplan: It seems to me that it still can be respectful of somebody's right to choose if you say you have to watch a video program about vaccines or certify that your doctor discussed the risks and benefits with you. I don't think those requirements are too intrusive into somebody's liberty.

Dr. Offit: My problem is this: Is it your right to choose to put your child at risk and those who are going to come in contact with your child? On the one hand, we are trained as physicians to be open to all attitudes and beliefs. On the other hand, we watch children come into our hospitals. Every year, at least 1 will die of an infectious disease, and when you watch that happen -- when you watch a child get flu, for example, and come into the hospital initially on face-mask oxygen, and go onto a ventilator, and then an oscillator, and then a heart/lung machine, and then die -- you see those parents slowly watch their child fall off a cliff. When another parent comes to you a week later and says, "I don't want to give my child a flu vaccine," it's very hard to be passionate and say, "It's your right to choose." I just don't feel that way.

Expand Vaccines for Pregnant Women

Dr. Caplan: We have spent a lot of time trying to figure out how to manage resistance, fears, and doubts. Where are we going? What is coming down the line? Are we going to continue to give vaccines through needles? Are we going to have the same array of vaccines, or are new ones imminent? What does the future hold with respect to vaccination?

Dr. Offit: I predict that the next great platform will be the pregnancy platform. You are already seeing it to some extent. We now give the whooping cough vaccine in the third trimester of pregnancy to try and prevent the deaths of 20-30 children every year from whooping cough, all of whom are less than 2 months of age. That is the only way to prevent that.

Dr. Caplan: And they die because they don't have any immunity to it?

Dr. Offit: That's right. They are too young to have developed an active immune response, and too young to be vaccinated. The first vaccine is given at 2 months of age, so that is why we give pregnant women a pertussis vaccine. We give the flu vaccine primarily to protect the mother who is pregnant and who has a 7-fold increased risk of developing pneumonia and dying of it than if she was not pregnant. We could have a meningococcal vaccine in pregnancy to avoid the need for the meningococcal vaccine that is given in the first year of life. I would like to think that down the line, we will have a respiratory syncytial virus vaccine that is given during pregnancy.

Dr. Caplan: Those are disorders that people often mistake for the flu.

Dr. Offit: Another disease is group B streptococcus. All of those would be reasonable vaccines to give to pregnant women, and they would benefit the newborns.

Dr. Caplan: There is more to be said here, but hopefully we have provided some useful information, solid tips, and maybe even some management strategies to those in the field who are trying to engage vaccination.

Thank you for all of the work you have done to promote vaccination and grapple with these questions in public. You have been a great example to physicians who say to me often, how do I engage? What do I do? You write, you speak, you go toe-to-toe with critics on national television or at a local high school assembly. You have shown a clear-cut path as to how that should be done.

Thank you for watching Close-Up With Art Caplan.

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