Issue 4 / 9 February 2015

THE US is currently in the grip of a fierce debate about childhood immunisation, triggered by an outbreak of measles, which appears to have originated in California’s Disneyland theme park early in the New Year.

The debate became increasingly heated with a Centers for Disease Control and Prevention announcement last week that there were more than 100 cases of measles in the US in January 2015, and that most cases were in people who had not been vaccinated.

Under intense media attention, the battlelines were clearly demarcated. Many organisations and individuals pointed out that vaccine refusers and the anti-vaccination movement were to blame for the resurgence of measles in the US.

Much of the coverage focused on the recklessness, stupidity and selfishness of refusing vaccination. Some social media posts were attributed to doctors voicing their frustration and their growing reluctance to treat unvaccinated patients and their families.
    
Political figures also joined the fray — some reprised the age-old political tension between personal choice and public good. Others showed clear leadership: President Obama stated that there was “every reason to get vaccinated” and a tweet from Hilary Clinton equated refusal to vaccinate with belief in a flat earth.

Discussing the outbreak and the problematic patches of vaccine refusal in the US, one paediatrician told The Economist that a big problem for immunisation was that most parents had never seen the diseases they were vaccinating their children against. “In the end”, he concluded “people don’t get vaccinated because they don’t fear these diseases.”

It is this sentiment, along with the knowledge that even the medical profession’s memory of some vaccine-preventable diseases is fading, that prompted retired Australian infectious diseases physician, Professor Clem Boughton to update, digitise and post a public education video from the 1990s, showing children affected by vaccine-preventable diseases.

In a comment for MJA InSight this week he encourages doctors to watch and share it with patients who are doubtful about the benefits of immunisation.

Australia had its own skirmish in the vaccination arena early in the New Year when there was strident opposition to a planned speaking tour by prominent American anti-vaccination campaigner Sherri Tenpenny.

Tenpenny eventually decided not to come citing security fears due to threats from “pro-vaccine extremists”. While a more likely reason was cold feet by individual venues, the episode divided the community, including doctors, along the lines of freedom of speech versus “deliberate dissemination of dangerous misinformation”.

These latest battles in the “vaccine wars” are in some ways encouraging: the voice of scientific reason has received widespread coverage and community backing, while the anti-vaccinationists have been shamed.

But there are also dangers in framing any health endeavour in such combative terms. In her first MJA InSight column for the year, Jane McCredie highlights a study conducted by Australian psychologists in a similarly conflicted field — climate change. The researchers argue that strident opposition can strengthen sceptics’ identification as part of a group, and their resolve to achieve their goals. Similar concerns have been expressed in the US press in the past few days.

At the height of the controversy over Tenpenny’s visit, vaccination experts Julie Leask and Katie Attwell reminded readers of Australian Doctor that entrenched vaccination refusal is the tip of the iceberg, with many parents simply lacking opportunities to vaccinate or experiencing hesitancy that is amenable to support and information. Time and effort, they suggested, is best spent on this group, while building trust and rapport and “keeping the door open” to entrenched decliners.

This is good advice, which I suspect reflects the practice of many doctors. It also eliminates much of the perceived conflict.

De-emphasising the “us” and “them” in the immunisation debate might just mean that one day (at least in everyday practice), the vaccine wars will be over — if we want them to be.

 

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight


Poll

Should doctors consider refusing to treat non-immunised patients and their families?
  • No - it's unethical (59%, 84 Votes)
  • Maybe - if they are a health risk to others (26%, 37 Votes)
  • Yes - it sends a strong message (15%, 21 Votes)

Total Voters: 142

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11 thoughts on “Ruth Armstrong: Battlelines

  1. John Cunningham says:

    The opinion piece of Julie Leask was an opinion piece, devoid of evidence to back up their claims. Stop the AVN, which lead the charge against Tenpenny, as collated evidence and presented it and last year’s PHAA that shows that since we started “shaming” the anti-vaxx rhetoric, we have turned the table on the manner in which media reports on them. It is a technique that has worked whilst others putting forward a more gentle “touchy-feely” approach have done nothing. Nothing. There is no evidence that their approach works, and in fact, now that CO have to be registered, there is evidence that the perception that some parents simply forget is fundamentally flawed. Good on Australian doctors and media for putting anti-vaccination misinformation in it’s place, I say!

  2. Elizabeth Hart says:

    MJA InSight’s poll asking “Should doctors consider refusing to treat non-immunised patients and their families?” raises important questions.  For example, what is the definition of ‘immunised’? How is this verified in an evidence-based way?

    Also, considering whether doctors are entitled to refuse to treat “non-immunised patients and their families” we must also consider healthcare providers’ duty to obtain valid consent before a medical intervention. For instance, The Australian Immunisation Handbook 10th Edition 2013 states:

    2.1.3 Valid Consent…For consent to be legally valid, the following elements must be present:

    1. It must be given by a person with legal capacity, and of sufficient intellectual capacity to understand the implications of being vaccinated.

    2. It must be given voluntarily in the absence of undue pressure, coercion or manipulation.

    3. It must cover the specific procedure that is to be performed.

    4. It can only be given after the potential risks and benefits of the relevant vaccine, risks of not having it and any alternative options have been explained to the individual.

    (My emphasis) Reference: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-2-1

    Are all healthcare providers obtaining ‘valid consent’ before the medical intervention of vaccination?

  3. John Cunningham says:

    Elizabeth Hart, do you have any evidence that they are not? Given the volume of reliable information available to GP’s and their patients, with full disclosure being one of the most important principles in patient communication, who is to say they are not?

    And since your emphasis includes discussing alternatives, what alternatives do you think should be discussed?

     

  4. Department of Health Victoria Clinicians Health Channel says:

    Ii is important in the context of any debate on immunisation, to mention what we, as a community, can do, to minimise the risk of young infants acquiring potentially life-threatening Pertussis infection. In line with recommendations in the U.K (1) and U.S.A (2), the draft chapter on Pertussis in the 2015 Update of The Australian Immunisation Handbook,10th. Edition (3) includes recommendations that all pregnant women receive a booster dose of dTpa vaccine during the third trimester of each pregnancy, ideally from 28th to 32nd week of gestation, regardless of when they have previously received the vaccine. As stated in the draft updated chapter, “vaccine-induced pertussis antibodies wane over time and the protective antibody level required in newborn infants is unknown. It is therefore possible that if a mother is not revaccinated during a subsequent pregnancy (even if closely spaced), her newborn will not be adequately protected”(3).

    References:
    1.Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women.Advisory Committee on Immunization Practices (ACIP), Morbidity and Mortality Weekly Report. 2013;62(7):131-135.

    2. N.H.S. “Whooping Cough and pregnancy.2014 edition.

    3. The Australian Immunisation Handbook 10th Edition, 2015 Draft Update. Chapter 4.12 Pertussis.

     

     

  5. Elizabeth Hart says:

    In regards to ‘alternative options’ to vaccination, there is a problem with the two doses of live Measles/Mumps/Rubella (MMR) vaccine dictated by the National Immunisation Program as, according to the GlaxoSmithKline PRIORIX Product Information leaflet, most seronegative children are likely to be immune after one dose of live MMR vaccine.

    It is my argument that people should be given the option of antibody titre testing to verify a response after the first dose of live MMR vaccine, even if they have to pay for this themselves.  It is my contention that if people are not properly informed of the option of antibody titre testing to check a response, then they are not giving their ‘valid consent’ to the second dose of live MMR vaccine, as they have not been properly advised of ‘alternative options’.

    I raised this matter with Dr Steve Hambleton, then President of the AMA, in May 2014, but he did not deign to respond.  My email to Dr Hambleton can be viewed via this link: http://users.on.net/~peter.hart/Email_to_Steve_Hambleton_AMA_re_MMR_seco

    In my email to Dr Hambleton I note that parents of small children might be surprised to discover that vaccination ‘best practice’ for companion animals is now more advanced than that for children, i.e. “…the principles of ‘evidence-based veterinary medicine’ would dictate that testing for antibody status (for either pups or adult dogs) is better practice than simply administering a vaccine booster on the basis that this should be ‘safe and cost less'”.

  6. John Cunningham says:

    Most, but not all, hence the need for the current schedule. What you’re proposing would raise the costs and trauma of vaccination for what purpose? To potentially decrease the rate of coverage. No wonder no one answers you.

  7. Randal Williams says:

    Those against general vaccination are ignoring the stark lessons of history. Do they avail themselves of other medical treatments such as antibiotics, safe anaesthesia and surgery etc, and do they otherwise trust the medical profession to advise in their best interests? If so then their approach is irrational.  Graphic depictions of the ravages of smallpox, diphtheria, poliomyelitis, epiglottitis etc etc might be needed to educate the modern New Age  parents who, because of herd immunity  have never seen these previously deadly conditions .

  8. tom gavranic says:

    We have failed to keep up with the times with our immunisation programmes. Parents today have no conception as to the nature of the diseases we are vaccinating against. Vaccination should be regarded as a “right of passage”, performed in a public space, with video facilities, showing inviduals suffering from these diseases.
    .
     

  9. Sue Ieraci says:

    Ms Hart is an active campaigner against what she terms “over-vaccination” – initially motivated by the vaccination of companion animals. It is possible that her concerns about the frequency of vaccination of pets may be valid  – this would require the expert opinion of someone with veterinary expertise.

    The human vaccination schedules, however, are based on evidence of seroconversion timing and duration, as well as the practicalities for families. The aim is to maximise population coverage, maximise immunity and minimise risk. These schedules have input from expert paediatricians, immunologists, infectious diseases and public health specialists.

    Her proposal that each child should be tested for antibody levels individually after each dose is both unnecessary and expensive, not to mention cruel for the child. In adulthood, in contrast, antibody levels are regularly checked to see whether boosters are required. This is a rational clinical approach.Ms Hart has no background in any scientific field or research. She is perfectly entitled to express her opinion, but she is not automatically entitled to credibility.

  10. Elizabeth Hart says:

    I am arguing for parents and other individuals to be given the option of a blood test to verifiy immunisation after the first dose of live MMR vaccine, before revaccination with the second dose.  This is not an ‘anti-vaccination’ argument, but it appears any challenge to the status quo and the scientific/medical establishment is not to be borne.  

    It is notable that in the state of New Jersey in the United States, the health department provides information on antibody titre testing.  The Antibody Titer Law (Holly’s Law) allows parents to seek testing to determine a child’s immunity to measles, mumps and rubella before receiving the second dose of MMR vaccine: http://www.state.nj.us/health/cd/documents/antibody_titer_law.pdf

    The Antibody Titer Law was enacted in response to the death of five year old Holly Marie Stavola who died of encephalopathy which she developed seven days after receiving her second dose of MMR vaccine: http://hopefromholly.com/blog/our-purpose/

    Why aren’t we all allowed to have this option?

    Information on antibody titre testing continues to be withheld from parents and other individuals.  Withholding lack of alternative options to vaccination and curtailing people’s right to ‘informed consent’ is a serious matter.  I hope that those complicit in restricting information will be brought to account.

  11. Sue Ieraci says:

    Ms Hart – imformation on antibody testing is not withheld – it is routinely used in adults to assess whether the person has ongoing immunity or whether they need boosters. Any GP can order titre testing. The reason it is not routinely done in small infants being vaccinated is that the blood draw for titres is painful and invasive, and the test is expensive. It is neither banned nor hidden, however. If this is truly the basis of your campaign, it appears to be based on a false premise.

    I also note this quote from your website: “I am challenging the increasing number of questionable vaccines and repeat vaccinations being foisted upon children, adults and animals by the burgeoning and unfettered vaccine industry.” Which are the “questionable” vaccines being given to children?

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