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Tuesday Feb 17, 2015

At a Loss: If Educating Parents About Vaccines Won't Work, What Will?

Fifteen years ago, the CDC declared measles had been eradicated in the United States. But last year, there were more than 600 cases reported in 27 states. As of Feb. 6, there were 121 cases reported in 17 states(www.cdc.gov) this year.

The vast majority of recent cases were linked to an outbreak that originated at Disneyland. The high number of cases and the high-profile location has sparked some interesting and controversial debates ranging from discussions about a federal vaccine mandate for the collective good to parents' right to choose for their children. And in certain circles on the Web, I’ve noticed some are rehashing the demonization of vaccinations sparked by faulty evidence.

© 2014 David Mitchell/AAFP

A 1-year-old girl receives the measles, mumps and rubella vaccine. More than 120 cases of measles have been reported to the CDC already this year.

However -- and I can’t believe I’m writing this -- on this subject I agree with Hillary Clinton. The former senator (and a presumed candidate for the Democratic presidential nomination in 2016) recently responded to a pair of Republican presidential hopefuls who had spoken in favor of parental choice with a tweet that said, "The earth is round, the sky is blue, and vaccines work. Let's protect all our kids."

Although the debates continue, this outbreak has presented only one question for me as a family physician: How can I convince parents who refuse to vaccinate their children to change their minds? The measles, mumps and rubella (MMR) vaccine is a poster child for immunizations. More than 95 percent(www.cdc.gov) of people who receive a single dose develop immunity to all three viruses. Measles, on the other hand, is a poster child for contagion, causing infection in 90 percent of unvaccinated individuals(www.cdc.gov) who come in contact with an infected person.

The decision to vaccinate would seem simple enough to me even though I've never even seen a case of measles. After all, it was declared eradicated before I started medical school.

But maybe that's part of the problem. Before the vaccine was introduced in the 1960s, measles was nearly as common as death and taxes. Parents had good reason to fear it. There were 3 million to 4 million cases(www.cdc.gov) annually in the United States. People were familiar with the illness and the problems it could cause, including hospitalization, pneumonia, blindness, brain damage and death. Most moms likely could have made the diagnosis at home even without the Internet.

But now I wonder if I could make the diagnosis. Seriously, before this highly publicized outbreak, how many of us were closely examining a child with fever and runny nose for Koplik's spots? I think younger generations of parents have no idea of the devastation this disease can wreak, and without that fear, not vaccinating seems like a viable alternative to some parents.

Keeping that in mind, education had been my approach to vaccine-hesitant parents in the past. Surely if I could impress upon them the risks of the disease -- not only to their own children but to others', as well -- and then illuminate the infinitesimal risk posed by vaccines, they would be overwhelmed by the logic of it all. When I think back on this, I realize I had limited success, and those battles were hard won.  

In fact, there is good evidence to support that this approach is likely folly. An interesting article(pediatrics.aappublications.org) published last year in Pediatrics looked at this issue and determined that this approach is not effective. In fact, in some instances it makes parents less likely to vaccinate their children.

So I do not admit this often, but I am at a loss. I need your help. This is a pressing issue in our practices at a time when isolated measles outbreaks are on the rise, fueled by pockets of unvaccinated children. The tool I had always considered my most powerful -- educating parents and partnering with them in decision-making -- appears to be broken.

On a personal note, I have good friends with four children who subscribe to a "natural" approach with their children, who are not vaccinated. Although we agree on some health care issues, such as avoiding overuse of antibiotics and over-processed foods, we don't agree on this subject. The mother recently posted a link on Facebook to a site that discourages vaccinations. Although I know immunizations are important, and I worry for these children, I am struggling with how to approach these situations without alienating this family, as well as parents in my practice who have similar beliefs.

Although the evidence has indicated what does not work, there are no studies that I have found that tell us what will work. It is in these instances when the family of family medicine is the most important. If anyone has an approach that has worked well, please share it in the comments below.

Peter Rippey, M.D., enjoys outpatient family and sports medicine practice in a hospital-owned clinic in South Carolina.

Posted at 01:17PM Feb 17, 2015 by Peter Rippey, M.D.

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