If you haven’t guessed yet, as in other countries in Europe, we are seeing more deaths from measles simply because folks aren’t vaccinated and more people are getting measles.
Measles is a life-threatening disease, even in an age of modern medicine, indoor plumbing, sewage systems, clean water, whole foods, vitamins and minerals, etc.
Italy, with about 1/5 the population of the United States, but about equal to the size of California, has had over 600 times as many cases of measles as we have had in the United States over the last few years. To put it in perspective, that would be like having 33,000 cases of measles in the United States.
But shouldn’t folks have a choice about getting vaccinated?
Even with the new vaccine laws, parents have a choice. As with vaccine laws in the United States, Italy’s new vaccine mandates had nothing to do with forced vaccination.
That’s unlike most of the people who died of measles in Italy. Most of them didn’t have a choice about being vaccinated and getting measles. Some were immunocompromised and couldn’t be vaccinated and at least one was too young to be vaccinated.
Parents had been set a July 10th deadline to provide schools with the relevant documentation, but it will now be possible for parents to simply submit their own confirmation that the child has been vaccinated, according to Giulia Grillo, Italy’s Health Minister, who was speaking at a press conference on Thursday.
Mandatory vaccinations: Italian parents will no longer need to provide doctor’s note
And that’s why it’s unfortunate that the a newly elected government severely watered down a vaccine law that had made getting vaccinated mandatory to go to school.
And it’s unfortunate that people continue to push misinformation about vaccines and vaccine-preventable diseases.
What to Know About the Measles Deaths in Italy
A drop in vaccination rates has led to measles outbreaks and a number of measles deaths in Italy.
Dr. Taz is on a mission “to transform the way we do medicine and empower and equip you with the best tools so you can live your healthiest life.”
While that sounds very nice, it doesn’t take too long to figure out that she seems like every other anti-vaccine quack we run across these days.
Who Is Dr. Taz?
Dr. Tasneem Bhatia MD (Dr. Taz) describes herself as a nationally recognized “wellness expert” who became a “pioneer and trailblazer” after overcoming her own personal health problems.
With multiple office locations and membership packages, Dr. Taz is pleased to offer many non-evidenced based services for you and your child, and she will even file your claim forms from your insurance company, although, as expected, she doesn’t actually participate in any insurance plans.
What about vaccines?
“My journey in medicine began with pediatrics, so I am well aware of the importance of vaccines and the incredible history and success of vaccination programs in reducing infant and child mortality.
Yet as my journey continues, I have had to listen to patient after patient describe a change or a shifting in their children once vaccines were administered. I experienced this as a parent. I will never forget the day that my son received a combination vaccine. Within 24 hrs., his mild reflux became severe, his weight gain over the next few months slowed and we continue to play catch up, trying to analyze our next steps. My son, however, is not autistic. He is brilliant, hilarious, and an absolute charmer.
My patients and my own children have forced me to rethink this vaccine controversy.”
Dr. Taz on Back to School Survival Series Part Two, The Vaccine Debate Continues
And parents can get a detox screen “which will directly correlate with your child’s early ability to detox and process chemicals.” That’s probably just MTHFR testing, which you don’t need and which doesn’t correlate with much of anything, besides homocystinuria.
Now, I understand that these types of holistic docs push the idea of “pulling from conventional, integrative, holistic, functional and Chinese medicine to create the best customized treatment plans possible,” but if any of these alternative therapies worked, whether it was acupuncture or Ayurveda, or homeopathy, then why do they need to integrate them all?
So what services does Dr. Bhatia offer to bring her patients to “whole health”? It’s a veritable cornucopia of quackery. Homeopathy? Check. Acupuncture? Check. (Obviously.) IV vitamin therapy? Check. Oh, and of course Dr. Bhatia offers thermograms. She even offers mobile thermograms. Never mind that thermography remains an unvalidated test for the early detection of breast cancer, much less for all the other conditions for which Dr. Bhatia recommends it, such as arthritis, fibromyalgia, back injuries, digestive disorders, “and more…”
A commercial for acupuncture masquerading as news
And how does someone go from teaching medical students and residents at Emory University to being one of Gwyneth Paltrow’s Goop experts, along with Kelly Brogan?
They bleed into their joints, into their skin (hematoma), and from their mouth and gums. They can bleed after surgery and even after getting their vaccinations.
Vaccines and Hemophilia
Having hemophilia is certainly not a contraindication to getting vaccinated though.
“Your child should get regular immunizations with necessary precautions to prevent bleeding from the injection sites.”
There are some precautions that are recommended before giving vaccines to a child with hemophilia, including:
using a 23-gauge or smaller caliber fine-gauge needle – consider a 25- or 27-gauge needle
when possible, giving the vaccine SQ instead of IM – for example, although the IPV (polio), hepatitis A, and hepatitis B vaccines are usually given IM, studies have shown that they can be given SQ to kids with hemophilia
applying firm pressure, without rubbing, after the vaccine is given for at least two minutes and up to 5 to 10 minutes
giving acetaminophen for pain relief, if necessary, instead of ibuprofen
warning about the risk of a hematoma developing at the injection site
Most importantly, if the child with hemophilia is already getting routine prophylaxis to prevent bleeding, schedule their vaccines around the same time to decrease the risk of bleeding.
Your child’s hematologist will likely give you specific instructions to provide to your pediatrician regarding immunization precautions.
What to Know About Vaccines and Hemophilia
Kids with hemophilia should get all of their vaccines on schedule, but precautions should be taken to decrease the chance of bleeding after getting an immunization.
The way that these laws and exemptions are set up leaves a lot of room for abuse though.
Abuse of Religious Exemptions
How many religions are actually against kids getting vaccinated?
That’s right, almost none.
So why are there so many religious vaccine exemptions in most states, especially in states that don’t have a personal belief exemption?
Folks who don’t want to vaccinate their kids, and can’t use a personal belief exemption, just say that vaccinating them would be against their religion.
Abuse of Medical Exemptions
There are some children who shouldn’t be vaccinated.
These children can get a true medical exemption to one or more vaccines because they have a real contraindication or precaution to getting vaccinated.
“If a child has a medical exemption to immunization, a physician licensed to practice medicine in New York State must certify that the immunization is detrimental to the child’s health. The medical exemption should specify which immunization is detrimental to the child’s health, provide information as to why the immunization is contraindicated based on current accepted medical practice, and specify the length of time the immunization is medically contraindicated, if known.”
Dear Colleague letter regarding guidelines for use of immunization exemptions
a moderate or severe acute illness with or without fever (precaution)
a progressive neurologic disorder (precaution)
Most other things are “incorrectly perceived as contraindications to vaccination” and should not be a medical exemptions, including having :
a mild acute illness with or without fever
a mild to moderate local reaction
relatives with allergies
a family history of seizures
a stable neurologic condition
an autoimmune disease
a family history of an adverse event after DTP or DTaP administration
A medical exemption can also exist if your child already had the disease and so has natural immunity. In most cases, except for chicken pox disease, titers will likely need to be done to prove that your child already has immunity.
Stopping the Abuse of Vaccine Exemptions
We know that vaccine exemptions are being abused.
How do you stop it?
“Permitting personal belief exemptions and easily granting exemptions are associated with higher and increasing nonmedical US exemption rates. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence.”
Omer et al on Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence.
You likely have to make it harder to get a vaccine exemption.
Strong exemption laws, which are needed in many states, make it clear that:
many exemptions are temporary
medical exemptions are based on ACIP guidelines, current accepted medical practice, and evidence based medicine – not anecdotes
religious exemptions specifically exclude philosophical exemptions and must reflect a sincere religious belief
exempted students will be excluded from school during outbreaks
exemptions should include a signed affidavit that is notarized
exemptions should be recertified each year
a separate exemption application will be needed for each vaccine
“Because rare medically recognized contraindications for specific individuals to receive specific vaccines exist, legitimate medical exemptions to immunization requirements are important to observe. However, nonmedical exemptions to immunization requirements are problematic because of medical, public health, and ethical reasons and create unnecessary risk to both individual people and communities.”
AAP on Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance
You could also get rid of nonmedical vaccine exemptions.
Of course, for that to work, you can’t allow just anything to count as a medical exemption.
“Review of all medical exemption requests will be conducted at the Mississippi State Department of Health by the State Epidemiologist or Deputy State Epidemiologist.”
Mississippi Medical Exemption Policy
In Mississippi, for example, where medical exemptions are reviewed and approved by the State Epidemiologist or Deputy State Epidemiologist, there were just 208 medical exemptions in the whole state during the 2016-17 school year.
In some states, rates of medical exemptions might be six or seven times higher. This is mostly seen in states that don’t allow personal belief exemptions and make it difficult to get a religious exemption.
That seems to be the case in Nebraska, where there are no personal belief exemptions and you have to submit a notarized statement to get a religious exemptions. Their high rates of medical exemptions likely reflect some abuse and the fact that medical exemptions aren’t reviewed or approved by anyone, they just reflect “that, in the health care provider’s opinion, the specified immunization(s) required would be injurious to the health and well – being of the student or any member of the student’s family or household.”
As we are seeing, that simply invites vaccine exemption abuse.
Very few states currently require that exemption applications go to the health department for review. Those that do include Alabama, Arkansas, Michigan, Minnesota, Mississippi, and West Virginia.
California is notably absent. I guess they didn’t see the potential for abuse when they passed their latest vaccine law. I mean, who could have guessed that doctors would actually be selling medical exemptions to parents based on unrelated conditions, like a family history of diabetes, celiac disease, or autism?
At the very least, until we have stronger exemption laws, parents who want to get a nonmedical exemption should acknowledge that they understand the risks they are taking when they skip or delay their child’s vaccines.
What to Know About Abuse of Vaccine Exemptions
While medical exemptions are necessary for kids who have true contraindications to getting vaccinated, stronger laws can help decrease the abuse we see in medical, religious, and personal belief vaccine exemptions.
Extremely few people can’t get at least some, if not most, of their vaccines, even if they do have contraindications to some others. And many exemptions are temporary.
“Parents need to balance the need of the immunoreconstituted child (post-transplant SCID) to be protected from exposure to infection from live vaccines and close contact–transmitted vaccine-derived infection with the need of the child to integrate into society and develop social and learning skills in group environments.”
Medical Advisory Committee of the Immune Deficiency Foundation
They also try to avoid people who are sick and try to make sure that everyone around them is vaccinated to help maintain herd immunity levels of protection.
Neither is always possible though.
Post-exposure prophylaxis is another option that is available to help prevent some vaccine-preventable diseases. For example, if your unvaccinated child is exposed to measles, they can often receive immune globulin to help them avoid getting measles.
Regimens for post-exposure prophylaxis are also available for:
chicken pox – varicella zoster immune globulin or immune globulin
diphtheria – antibiotics
hepatitis A – immune globulin
hepatitis B – hepatitis B immune globulin
influenza – oseltamivir (Tamiflu) and zanamivir
meningococcal disease – antibiotics
pertussis – antibiotics
rabies – rabies immune globulin
tetanus – tetanus immune globulin
When possible, immunization typically accompanies these post-exposure prophylaxis regimens.
There is one big problem with these types of post-exposure prophylaxis regimens though. You are not always going to know when your child is exposed to someone else with a vaccine-preventable disease. While some exposures might be obvious, like if your child steps on a rusty nail or is bitten by an unvaccinated dog who has rabies, you might miss some others.
Bogus Alternatives to Getting Vaccinated
What other alternatives to getting vaccinated are out there?
Unfortunately, there are none that work.
Many bogus alternatives to getting vaccinated are pushed by those opposed to vaccines as ways to boost your immunity, and they can include:
breastfeeding – while breastfeeding is great and always encouraged, the passive immunity it provides will not protect your baby from most vaccine-preventable diseases, as it contains IgA antibodies, not the IgG antibodies you would need to prevent diseases like measles, tetanus, chicken pox, and Hib, etc.
homeopathic vaccines – nosodes are homeopathic vaccines that have been diluted so much that they are supposed to retain a memory of the original substance. Even if they did – that’s not how immunology works.
herbs – neither echinacea, goldenseal root, nor elderberry syrup is going to boost your child’s immunity
vitamins – unless your child is severely vitamin deficient, taking vitamins isn’t going to boost their immunity, whether they are taking extra vitamin C or extra vitamin D
foods – Japanese mushrooms, kale, broccoli, lettuce, cabbage, avocados, ginger, black currants, graviola, green veggies, onion seeds, and berries might all be great to eat, but they aren’t going to boost your immunity
probiotics – they may help prevent antibiotic associated diarrhea, but there is not much evidence that taking them regularly does anything else
essential oils – they sometimes smell nice, but they aren’t going to boost your child’s immune system
sun exposure – in addition to the worries about skin cancer, not only does extra sun exposure not boost your immune system, the WHO reports that “Several studies have demonstrated that exposure to environmental levels of UV radiation alters the activity and distribution of some of the cells responsible for triggering immune responses in humans. Consequently, sun exposure may enhance the risk of infection with viral, bacterial, parasitic or fungal infections, which has been demonstrated in a variety of animal models.”
fermented cod liver oil – this is not going to boost your child’s immune system, but folks should also know that there have been reports that the products that people have been buying and using for years were rancid and actually making them sick! There are much better ways to get vitamin D and vitamin A in your diet than taking fermented cod liver oil each day.
What about natural immunity?
While natural immunity can in some ways be more effective than vaccine induced immunity, it often comes at a price. You have to recover from the disease, hopefully without any long term consequences, to develop natural immunity.
What to Know About Alternatives to Getting Vaccinated
People who truly can’t be vaccinated rely on herd immunity, because in most cases, there are no effective alternatives for vaccines.
There are some true medical contraindications and precautions to getting vaccinated though. Still, it is important to remember that even more things are simply “conditions incorrectly perceived as contraindications to vaccination.”
Contraindications To Vaccinating Your Kids
There are actually some good reasons to delay or skip one or a few of your child’s vaccines, but only in some very specific situations.
These very specific situations are called contraindications and are what count as medical exemptions.
“A vaccine should not be administered when a contraindication is present; for example, MMR vaccine should not be administered to severely immunocompromised persons.”
CDC on Vaccine Contraindications and Precautions
Fortunately, there are not that many of these contraindications, they are usually specific to just one or a few vaccines, and they are usually, but not always, temporary.
That’s why it would be really unusual to get a true permanent medical exemption for all vaccines. Even if you had a severe allergy to a vaccine that contained yeast, latex, or gelatin, since vaccines contain different ingredients, you would very likely be able to safely get the others.
Remember, your doctor can’t, or at least shouldn’t, just make up contraindications and exemptions to help you avoid getting your kids vaccinated and help you keep them in school.
“I do not believe vaccines had anything to do with my child’s autism. I never noticed any change in his speech, behavior or development with vaccines. I believe the protection and benefits of vaccines far outweigh the risks!”
Michele Han, MD, FAAP
Autism, for example, has been shown to not be associated with vaccines, so it is not a contraindication to getting vaccinated. That’s why many parents vaccinate and protect their autistic kids!
Precautions To Vaccinating Your Kids
In addition to contraindications to getting vaccinated, there is an accompanying list of precautions.
“A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction, might cause diagnostic confusion, or might compromise the ability of the vaccine to produce immunity (e.g., administering measles vaccine to a person with passive immunity to measles from a blood transfusion administered up to 7 months prior). A person might experience a more severe reaction to the vaccine than would have otherwise been expected; however, the risk for this happening is less than the risk expected with a contraindication. In general, vaccinations should be deferred when a precaution is present. However, a vaccination might be indicated in the presence of a precaution if the benefit of protection from the vaccine outweighs the risk for an adverse reaction.”
CDC on Vaccine Contraindications and Precautions
Again, we are fortunate that most of the conditions that are listed as precautions are temporary.
In fact, the most common is having a “moderate or severe acute illness with or without fever.”
Don’t want to get your child vaccinated when he or she has a severe illness?
Your pediatrician usually doesn’t want to vaccinate your child in that situation either.
It is easy enough to wait a few days or a week to get vaccinated, when the illness has passed, keeping in mind that a “mild acute illness with or without fever” is neither a precaution nor a contraindication to getting vaccinated. So you can still get your child their recommended vaccines if they just have a cold, stomach bug, or ear infection, etc.
What to Know About Precautions and Contraindications to Vaccines
Although there are some true medical exemptions or contraindications and precautions to getting vaccinated, most are vaccine specific and many are temporary, so they shouldn’t keep you from getting your child at least mostly vaccinated and protected.
More on Precautions and Contraindications to Vaccines
reminding parents to bring their immunization records with them to each appointment, especially if they are new patients
keeping accurate immunization records on each patient
carefully recording vaccines that have been given outside your office
using an immunization information system or immunization registry to make it easier to keep track of immunization records
generating lists of patients who’s vaccines are past due
using reminder and recall messages, either phone calls, text messages, or postcards, etc., so that parents are notified when vaccines are due soon or past due
using an electronic health record system to automatically generate prompts when vaccines are due at well visits and sick visits
manually reviewing your patient’s vaccination status at each visit, whether it is a sick visit, well visit, or just a nurse visit, to see if they need any immunizations. Remember, a mild illness is not usually a contraindication to getting vaccinated.
reducing missed opportunities to vaccinate kids by using standing orders and “nurse only” or “shots only” visits for vaccinations
having extended hours for some scheduled or walk-in vaccination clinics
“Pediatricians in the sample often provided parents with inconsistent, mixed messages and sometimes offered information about HPV or HPV vaccination that was inaccurate. Pediatricians used presumptive language in only 11 of 75 encounters; when used, presumptive language was associated with higher odds of accepting HPV vaccine.”
Sturm et al, on Pediatrician-Parent Conversations About Human Papillomavirus Vaccination: An Analysis of Audio Recordings
Pediatricians who are getting frustrated talking to parents who have been refusing vaccines might also learn a few new things, including how to use presumptive language.
What is presumptive language?
In the HPV vaccination study quoted above, it was defined as “a matter-of-fact statement that the child was due for or would receive HPV vaccine that day or at a future date, conveying a positive stance toward vaccination.” This is in contrast to a nonpresumptive style that “involved questions or uncertainty,” such as “do you want to get a shot today?”
“High-quality recommendations were strongly associated with HPV vaccination behavior, but only about one-third of parents received them.”
Gilkey et al, on Provider communication and HPV vaccination: The impact of recommendation quality
In addition to using presumptive language, another study has found that “By endorsing HPV vaccine highly, recommending same-day vaccination, and emphasizing cancer prevention, providers may be able to promote HPV vaccine initiation and completion while discouraging vaccine refusal and delay.”
Can these strategies work for your office?
What to Know About Increasing Childhood Vaccination Rates
From using reminder systems and standing orders to changing how you talk to parents, there are a lot of things that can be done to increase childhood vaccination rates.