How Can Further Measles Outbreaks Be Prevented And The Decline In Vaccination Reversed? – Confirmed measles cases in US tops 150 + Outbreak in Wales.

22 Jun

“The leaders of the antivaccination movement say they speak out because they care about the children. When I see stories like these, from parents who are destroyed by the loss or serious illness of the children, I question those antivaccination advocates. And we know that when trying to sway opinion, just stating facts rarely works against antiscience claims like those of antivaxxers. I’m hoping that more parents see stories like the ones at Shot by Shot. We have the facts on our side, but we also need to touch these parents’ hearts before they’ll see the truth.”

Phil Plait

via Confirmed measles cases in US tops 150 | Bad Astronomy | Discover Magazine.

This Phil Plait article and the USA Today article it mentions are recommended reading to anyone concerned about public health right now and for the future.

I haven’t fully explored this issue yet but it seems to me that doctors, nurses, health professionals, the media and governing bodies are not doing enough to ensure that parents are given a complete and fully informed choice. Which may mean that parents are not giving valid reasons for not vaccinating their children.

Some research has taken onboard the reasons why parents choose not to vaccinate their children such as this 2009, Increasing MMR Vaccination In London Report. In the UK vaccination seems more open to choice but in the US it appears to be more mandatory in many states but with some offering various exemptions. This University Of Michigan Journal Of Law Reform report, by Steve Calandrillo (2004) covers the US system quite well, with page 22 onwards exploring exemptions in detail, a key quote of this Calandrillo paper being:

“While most reasonably- minded physicians and health care professionals respect *413 parents’ deeply held beliefs about how to best raise their children, nearly all fear the rise of “exemptions of convenience.” These exemptions are so-named because they merely require that a parent check a box opting out her child out from vaccination so that she can attend school. They often occur at the last minute, when it is easier to mark the box than it is to complete the ACIP childhood immunization schedule. Certainly, most fair-minded people agree that an issue as important as vaccination should not be decided in haste and certainly not on the basis of expediency or convenience. “

I think that the problem with accepting ‘philosophical’ or religious reasons too easily, on face value is that it could be that there is more too it. If health experts are not fully exploring each individuals reasons for not vaccinating during a consultation then we cannot come to a full understanding of whether or not a person’s beliefs can be reconciled with the idea of vaccination.  It may be interesting to look at exploring how much information (or misinformation) these philosophical reasons are based on, how valid those beliefs are and how sincere.It may be that some parents use ‘religious reasons’ to cover up other underlying fears or worries about vaccination which would need to be addressed in a proper discussion of the evidence.

Some parents may not wish to discuss their opposing beliefs because they feel they will be judged or considered crazy, ignorant or not intelligent. It may also feel obtrusive for both the health professional and the patient to consider delving too deeply into a person’s private beliefs however vaccinating your child is not an individual choice but a public health choice and it is in the best interest of the community as a whole, as well as to you and your child individually, that health professionals and public bodies ensure that you fully understand the facts and evidence and make an informed choice. There is some evidence that this assurance is not being carried out in the US. The Calandrillo (2004) paper, explains that many states accept exemptions on the grounds of religious or philosophical beliefs at face value. With very few ever actually being turned down, or even questioned for sincerity. However, it also reports the state of New York’s Board of Education has come to the conclusion that no established religion actually forbids vaccination. Here’s the quote:

“few states rigorously police religious and philosophical exemptions or insist on their sincerity in practice. In fact, a 1998 study found that 32 of the 48 states that currently permit such exemptions have never denied an application for one. [FN410] New York is one of the notable exceptions, as its Board of Education takes the position that no established religion formally forbids vaccination. Dr. Terry Marx, the Board’s chief physician, states openly that “many applications are bogus” and that she rejects them “if they’re based on quackery.” [FN411] The state is one of just a handful that requires applicants to write detailed letters justifying their objections to prevent the spread of exemptions of convenience.”

 (37 U. Mich. J.L. Reform 353, Page 24- 25)

As well as avoiding exemptions of convenience I believe that it would also be of benefit to society that we all fully understand the reasons why some parents do choose not vaccinate, especially those who seek exemptions after receiving all of the relevant information concerning their issues and worries with vaccination. I’d also be interested how reassured or not this made them feel and the reasons why. Salmon and Siegal (2001) proposed “if states choose to offer nonmedical exemptions, they may be able to optimally balance individual freedoms with public good by considering the sincerity of beliefs and requiring parents considering exemptions to attend individual educational counseling”. This is something I find very agreeable. In support of Salmon and Siegal’s proposal this 2004 study in the UK agrees that educational counseling is helpful and suggests that a collaborative approach as part of an ongoing learning process for parents would be the most effective solution to this problem of vaccination decline.

I believe that it is vital in all health issues to ensure that all relevant information is presented in a transparent manner, this would increase trust. It is vital that this information has been fully understood, that the receiver of the information can present their concerns and questions without feeling judged negatively and from this the individual can make a fully informed decision which is based on the facts.

It would seem possible that in many instances it may be the case that the parent has already made up their mind and so the doctor may want to only briefly give the details of the benefits of vaccination but without exploring these reasons and answering any questions or fears more fully.

Therefore, it may also be of help to ensure that a health professional contacts parents who have decided not to vaccinate every few months to answer any further questions, to ensure that they are their to help and support the parent, and to see if the parent has changed their view or what other new thoughts have arisen in their mind.

Something like the ‘lecture’ idea in this Daily Mail article. Which also states that research has shown parents want more information on MMR vaccinations before making up their mind. Mary Creagh in The Guardian suggests what may be a fairly logical but largely unpopular idea akin to the US system as a solution which would involve parents proving their child has been vaccinated before their child can start school. This would be a measure which would prevent those with medical or otherwise ‘valid’ reasons not to vaccinate and/or those with weakened immune response due to drugs or illness (such as cancer) from coming into contact with the disease as well as ensuring herd immunity to prevent outbreaks.

There is also an interesting Pru Hobson-West, 2003, PSA article  which details how trust in the vaccination program, the doctor or nurse and the vaccine itself could play an important role in deciding whether or not to vaccinate. It also mentions that loss of trust in one vaccine can endanger the entire vaccination program, which is of great concern.Hobson-West’s 2004 paper challenges two relevant assumptions, 1) that concern about vaccinations is due to a miscalculation of risks and  2) that the best response to vaccination controversies is more vaccination statistics.

Interestingly, some recent research (Anderberg, Chevalier and Wadsorth, 2011) has demonstrated that it is those parents who stayed in education past the age of 18 who were more likely to have turned down MMR vaccination for their children, and that this also correlated with a decline in other non-controversial vaccinations, however wealthier parents tended to avoid the dilemma by purchasing single shot vaccinations. This isn’t a great solution though, as the BUPA website states “Where the MMR vaccine is available, no country recommends single rather than combined vaccines.” I like the Anderberg, Chevalier and Wadsorth (2011) paper because it demonstrates that well educated and likely intelligent parents were the first and most prevalent among parents who turned down vaccinations. This demonstrates that it is not simply being unintelligent or lacking the ability to investigate the issue which leads to parents turning down the vaccination. In my view this shows that everyone can quite easily become the victim of misinformation or reach illogical decisions on important matters. In accordance with Anderberg, Chevalier and Wadsorth (2011), Hobson-West (2004) and the Phil Plait quote which opens my article, it would seem emotions such as fear and trust play a large role in decision making when it comes to parents vaccinating their children. It may prove difficult to reassure the public through evidence and educational means alone. However, such attempts to inform the public and prevent exemptions of convenience do appear to be entirely necessary.

UPDATE: 28th June 2011

On the 27th June, the BBC Reported that an outbreak of 10 cases of measles has been confirmed in Ceredigion with investigations of further cases in Pembrokeshire, Neath Port Talbot, Swansea, Carmarthen, Powys and the old Gwent area. There are said to be 20 further cases currently being investigated and these cases have been attributed to many of the children not receiving their scheduled vaccinations. This seems to hammer home the relevance and urgency of educational campaigns and interventions encouraging vaccination. This comes after the first outbreak of measles in Leeds since 2009, reported in March this year identifying 15-20 cases and 2 children being hospitalized in Wirral this May after an outbreak including 7 other probable cases.

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