The vaccine controversy

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March Cover Picture2 (2)Sixty years ago an average of 400 Canadians contracted polio per year. Those who survived were left with a paralyzed nervous system and permanently maimed limbs. Today, polio is prevalent in only a handful of countries and eradicated in Canada thanks to routine immunizations against it and 12 other potentially fatal conditions. Along with flush toilets and clean water, routine immunizations, or vaccines, are considered the world’s most important defence against preventable diseases.

Surprisingly, while vaccines are free and readily available in Canada, cases of infectious diseases, like measles and pertussis (also called whooping cough), are on the rise. The resurgence is a result of Canada’s falling child vaccination rates – resulting from parental complacency and hesitancy, widespread misinformation, socioeconomic factors, cultural miscommunication, a fragmented national strategy and passive public health efforts.

“I feel this is a looming public health crisis,” explains Dr. Jane Finlay, a Vancouver-based practitioner who counsels vaccine-hesitant parents. Dr. Finlay is also a member of the Canadian Paediatric Society’s (CPS) Infectious Diseases and Immunization Committee. “I often hear concerns about formaldehyde in vaccines – but there is more in a peach than any of the vaccines,” explains Dr. Finlay, who tries to get parents to understand the serious risks associated with refusing vaccination. “When you are crossing the street are you looking up at the sky for an airplane to fall on you or are you going to watch for traffic?”

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In July 2013, the Public Health Agency of Canada identified 30 cases of measles in six different provinces – five times the number of cases confirmed by the same point in 2012. By the fall, Alberta confirmed 42 cases of measles. The province declared the outbreak over this past January – only to reissue a warning a few weeks later when new cases resurfaced. Measles is the leading cause of death in children worldwide and can cause pneumonia, deafness and brain damage. The vaccine has been available in Canada since 1963.

At least 13 children have died from pertussis in the past 10 years. The majority of deaths occurred in infants less than two months – they were too young to be vaccinated – highlighting society’s role in vaccinating to protect others. From October 2011 to April 2013, Ontario experienced a large outbreak with 441 cases. As Hospital News went to press, at least six people in Prince Edward Island had pertussis in 2014. That number seems certain to rise across the country.

How vaccines work

Vaccines expose the patient to a very small, safe amount of viruses or bacteria. The patient’s immune system learns to recognize and attack the infection in case of future exposure. As a result, the patient will not become ill or will suffer only a milder infection.

More importantly, vaccines protect society’s most vulnerable like newborns, the elderly, the immunocompromised, the pregnant or those who cannot be vaccinated because of medical reasons. By preventing contagion, vaccines shield the entire community. It’s harder to catch an illness, if those around you have already fought it off. This is also known as herd immunity. Collective resistance fluctuates by disease, but usually falls between 85 and 95 per cent. That’s why Canada’s falling child vaccination rate is so alarming.

A UNICEF study published last year found that only 84 per cent of Canadian children were immunized for measles, polio and DPT3, placing Canada in second-last place out of 29 of the world’s richest countries. (In contrast, Greece topped the list with a 99 per cent immunization rate –in spite of its instability and economic crisis.) Canada’s low childhood immunization rate makes it easier for these highly contagious diseases to find holes in our collective barrier.

The Public Health Agency of Canada (PHAC) contests the UNICEF study and says that the current vaccine coverage estimate for DTP, measles and polio, is over 95 per cent coverage. Even still, experts in the field say Canada could be doing a lot better.

“I am deeply embarrassed when I go outside of Canada to immunization meetings to come from an OECD country with such a poor immunization uptake rate,” says Dr. Noni MacDonald, professor of paediatrics at Dalhousie University, IWK Health Centre and Canadian Centre for Vaccinology.

Complacency and ambivalence fuel vaccine hesitancy

One reason Canadians are hesitant to vaccinate is the absence of imminently threatening disease. Without a visible present danger it’s easy for parents to grow complacent.

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“Canadians are privileged to live at a time when people no longer remember the severity and how common these illnesses were. Eighty years ago, it was common for children to pre-decease parents in their first five years,” explains Dr. James Talbot, Alberta’s chief medical officer.

It’s because of the generations before us, he says, that we live in a time when infant mortality is considered a tragedy, and not a common occurrence.

“A slide show of the average pediatric ward from the 1950’s and 1960’s would illustrate what catastrophes await,” warns Dr. Hirotaka Yamashiro, chair of the pediatrics section of the Ontario Medical Association and president of the Pediatricians Alliance of Ontario. “There is no doubt that the easy access to information, good and bad, has accelerated this process with misinformed or maliciously-inclined individuals given the same credibility as those who have expertise.”

This leaves the need to stress vigilance on the shoulders of practitioners – many who are struggling to have quality time with each patient. “The fee schedule encourages a higher volume practice so many can’t spend a half hour discussing vaccination,” says Dr. Finlay.

Physicians urged to be patient, persistent

“There are few downright refusers for all vaccines, but there are many who are hesitant,” says MacDonald. Finlay and MacDonald encourage health care workers to be patient with parents. They urge doctors to find out what’s behind the parent’s ambivalence. And while many doctors are tempted to dismiss the patient from their practice, Finlay and MacDonald argue it’s in the child’s best interest to be respectfully persistent with the parents – even if it takes multiple visits.

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“One of the most effective interventions with parents is to be a good listener. It is important to engage parents in a proactive, honest discussion, rather than lecturing. We also must address unfounded allegations about vaccines, refute misinformation and provide credible sites and resources,” says Shelley Landsburg, director of the communicable disease control with the office of chief medical officer of health in New Brunswick.

Alberta’s Chief Medical Officer of Health says every health encounter – even in social settings – is a valuable opportunity to improve outcomes. “The decision to get immunized is heavily influenced by health care professionals in personal and professional relationships. Never underestimate how you will affect a parent’s decision,” says Dr. Talbot.

The side effects of vaccines are minor when compared to the possible effects of not vaccinating: death, brain damage or permanent disability. The benefits, however, are overwhelming: less antibiotic use; fewer hospitalizations and invasive treatments and tests; fewer long-term disabilities and diminished risk of childhood strokes.

Misinformation messages online

Despite the overwhelming scientific evidence in support of vaccine safety, a quick Google search will reveal an active opposition. Purported ‘experts’ use flawed logic and science to contribute to parental confusion.

“Parents have access to a wealth of information and many sources of misinformation, including television documentaries, magazines, and hundreds of anti-vaccine web site links,” says Landsburg. “The difficulty for parents lies in trying to figure out which information to believe.”

Those parents who don’t vaccinate their children base their decisions on what they believe is sound research. One mother told Hospital News that she read an article on the negative side effects, which confirmed her intuition against vaccines. Another parent said scientific articles defend his choice not to vaccinate his 15-month-old son, citing a recent study that found vaccinated baboons infected others with the illness. The study justified his belief that vaccines are dangerous; meanwhile, the scientists who led the study believe their results will help improve vaccines.

“We need to teach the difference between one anecdotal case and high-quality scientific studies,” says Dr. Joan Robinson, a Pediatric Infectious Diseases specialist in Alberta.

“Vaccines are still the most cost effective way to ensure that you see your child graduate from high school or attend their wedding,” says Dr. Talbot.

Admittedly vaccines are not 100 per cent effective all the time. Three Calgarians diagnosed with measles this year were immunized for the illness. “We are still investigating those cases,” explains Dr. Talbot. “But even then, they were only mildly affected by measles. Compare that to the outbreak we had in south Alberta, where the community was not immunized. The spread was much faster.”

Still, Dr. Talbot’s assurances frequently fall on deaf ears.

“The anti-vaccine movement is small, but has a very large voice. Canadians are not immune to their messaging,” says Dr. Dan Flanders, director of Kindercare Pediatrics and staff physician at North York General Hospital in Toronto.

Pediatricians and emergency room physicians confront the consequences of online misinformation every day. One emergency physician told Hospital News of an intentionally unvaccinated toddler who was admitted with fever and a sore neck. The young child had to undergo blood tests and a spinal tap to rule out meningitis. The doctor says the child’s suffering and expensive procedures were both avoidable.

Unvaccinated adults are also at risk. “A patient came into our emergency department with weakness and couldn’t breathe properly. This patient was diagnosed with tetanus and almost died. Routine vaccinations and boosters could have easily prevented this,” says Dr. Glen Bandiera, chief of emergency medicine at Toronto’s St. Michael’s Hospital.

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Many unvaccinated patients’ parents base their decision-making on movement which grew from an infamous, and refuted, study published 16 years ago.

Debunking myths

In 1998, The Lancet published a study claiming a link between autism and the vaccines that prevent measles, mumps and rubella (MMR). The study was quickly called into question. The results could not be replicated by other scientists and subsequent research cleared the MMR vaccine of any connection to autism. The medical journal retracted the study and the lead researcher was stripped of his medical licence, and charged with acting “dishonestly and irresponsibly” in his research.

Other common concerns include that vaccines overload the immune system, and undermine the body’s natural ability to protect. Babies are born with antibodies but they are temporary, and leave the child vulnerable to deadly illnesses. There is no evidence that vaccines overload or overwhelm the system. There’s also no scientific evidence that vaccines or their ingredients, cause multiple sclerosis, brain damage, increase risk of asthma, or SIDS. Patients are encouraged to sit with a trusted health care professional and address all their concerns.

Other obstacles to vaccination

There are some parents, however, who don’t even know which questions to ask. Often these parents are new Canadians or struggle to meet basic needs because of low-income issues. “Our studies show that new immigrants, for whom language may be a bit of a barrier (…) they may not know that these things are available or that they are free,” explains Dr. Talbot.

Poverty is another factor according to studies out of Manitoba and Ontario.

“A number of factors influence childhood immunization rates. The most important ones appear to be mother’s age at child’s birth (>24 years old), higher family income, continuity of care, primary care physician, and having fewer than four siblings,” says Dr. Alan Katz, professor of Family Medicine and Community Health Sciences at the University of Manitoba, and associate director of the Manitoba Centre for Health Policy.

Collective protection vs. Individual choice

“Canadians respect the rights of individuals to make choices. In many countries childhood immunization is not a choice but is required by law. Others, like Australia, provide financial incentives to parents who have their children vaccinated,” says Katz.

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While Canadian law protects the right of the individual – ethically- vaccine advocates argue for the collective protection over individual choice. “If we can’t overcome vaccine hesitancy with education and supportive strategies, it may be time to consider making vaccination mandatory for a child to be enrolled in activities which bring them into contact with other children,” suggests Dr. Finlay.

One medical ethicist agrees. “It is ethically irresponsible to refuse vaccinations and put other children at risk,” says Maya Goldenberg, associate professor at the University of Guelph. “Your willfully unvaccinated child might spread the disease to a baby that hasn’t been vaccinated yet (too young) or someone who is immune-compromised and therefore unable to be vaccinated. Our public health system also needs to pay for those intentionally unvaccinated children that become ill and require care.”

Improving outcomes

Where Canada goes next in our efforts to improve vaccination rates is contested. Public health advocate and Globe and Mail Columnist André Picard has some suggestions.

“We need a single, coherent childhood immunization schedule (not 13 different ones in each province/territory); harmonized funding so the same essential vaccines are available to all Canadians; and a national immunization registry to link data across the country,” says Picard.

Alberta’s Dr. Talbot thinks a registry will do little to increase rates, but agrees that federal funding could help provincial initiatives. Both men agree that public health officials and health care providers need to amp up public health education and communicating vaccines’ benefits.

“Misinformation is widespread and public health officials are passive and timid,” says Picard. Picard also argues that we need to move beyond our exclusive focus on childhood vaccination and pay more attention to young adults. “The outbreaks of measles are in college-age kids who have no idea they’re not vaccinated; the mumps and pertussis outbreaks are in young adults who require boosters but we make no effort to reach out to them. And then there are seniors who could benefit from shingles vaccine,” says Picard.

CPS co-authors MacDonald and Finlay would like to see a national committee to examine vaccine hesitancy and develop strategies. “We are already seeing some provinces moving in this direction but we need to learn from each other and work together. Not fragment our talents and resources,” says MacDonald.

“There are already so-called national standards like NACI, but the problem is implementation,” explains Dr. Yamashiro. “The way federal funding of healthcare is decentralized makes it harder to create cohesiveness across the country. Unless there is a universal will to implement any such strategy, it would likely not be successful.”

All the health care advocates agree on one aspect: public education. They urge all health care workers to embrace the responsibility to debunk myths and be louder than the voices muddying the waters.

“I think the vast majority of parents want what is best for their children,” says Dr. Flanders. “Armed with the right information, and protected from false anti-vaccine propaganda, they will inevitably make the right choices for their children.”