Stop what you’re doing to read this The New England Journal of Medicine perspective by Dr Doug Diekema. It’s about vaccines, opportunities for health, and physician obligation. Written for physicians, it also speaks loudly to parents and includes a few very essential points. The whole time I read the article, my thoughts kept leaping to our imminent opportunities. Today, in 2012, we can harness the tools of social media and technology to solve many of these problems. It’s time. HPV vaccine? Varicella vaccine? Remember your yearly flu shot? I really think there could an app for that.
Let me explain.
Dr Diekema opens describing a scene very typical in Seattle.
Recently, the mother of a young child confessed to me that she didn’t know any parents who were following the recommended immunization schedule for their children. She said that when she told her pediatrician she’d like to follow an alternative schedule, the physician had simply acquiesced, leading her to assume that the recommended schedule had no advantage over the one she suggested.
Yes, the physician obliged her desired schedule for many reasons, I suspect: time restraints/desiring a partnership/a hope for future opportunities to provide education and update immunizations for the child. In a state (Washington) that leads the nation in vaccine exemptions, we encounter patients daily who prefer a delayed or personal schedule. I’ve written about parents and alternative schedules and physicians’ conditional comfort with alternative vaccine schedules. But when Dr Diekema mentions this family, he highlights what many pediatricians and family physicians realize: families may be clustered together in vaccine-hesitancy. Friends of friends instruct each about vaccine schedules and share beliefs about safety. We know that 40% of parents who use an alternative schedule create it themselves.
Family members persuade my patients not to get immunized. Even in the midst of a pertussis outbreak in the county in which I practice, grandparents and relatives of newborns refuse the Tdap vaccine. My patients are bombarded with advice and naysayers. Who we love (friends and family) and who we trust (friends and family) certainly affect what we do. My patients get confused. And most of health (care) conversations happen outside the exam room. Therefore, hesitancy clusters in neighborhoods naturally and poses regional risk. What if we had real time information about our schools? About our neighborhood? What if Google mapped our rates of protection from vaccinations? What if we had a smart phone app that provided us yearly data on school immunization/exemption rates when we selected a kindergarten? Why not an app for that?
So what if we gave new parents the tools to help educate Aunt Judy who refuses the Tdap shot. What if we handed her a Youtube video to share with Grandpa Bob while he rocked the newborn. Grandpa isn’t refusing a vaccine out of cruelty; he’s refusing it out of fear or possibly confusion. Why not give him the shot at the ped’s office too? Let our patients educate while cocooning and protecting their babies.
Data from the Pew Internet and American Life Project finds that 80% of internet users look up health information, but more, internet users want to use what they learn to help others. Many patients join disease-specific groups to crowd-source and share information about medical conditions/medication side effects/doctor visits. Most of us search for health information on behalf of someone else. Susannah Fox calls this learning and sharing Peer-to-Peer-HealthCare. She says the leading edge of health care is when patients say, “I know and I want to share my knowledge.” They use their mobile device to inform friends and family. New parents are learning how and why to protect newborns for pertussis in my clinic. What if we offered them a link with a video to share with relatives? Or an application of up-to-date infection numbers. Peer-to-peer health care is real and these new parents are strong, wise, and fierce protectors of their children. Why don’t doctors help them outside exam room walls? Young parents are savvy and already tracking the number of poopy diapers on their iPhone, so why are we not making a vaccine app?
In actuality, an alternative or delayed vaccination schedule only increases risk. All vaccines carry risk and waiting to get vaccinated only elevates risk by creating more time for a child to remain susceptible for infection, while still acquiring the small risk of the delayed vaccine. So these delays and these clusters of missed vaccinations become problematic. The Pacific Northwest is one example.
In Washington State’s San Juan County, for example, 72% of kindergartners and 89% of sixth graders are either noncompliant with or exempt from vaccination requirements for school entry. Only 52.5% of kindergartners and 4% of sixth graders were adequately immunized against pertussis for the 2010–2011 school year.1 Not surprisingly, the county also has one of the state’s highest incidence rates of pertussis.
It’s challenging to keep up with the immunization schedule. The 2012 schedule was just released and reflects new changes but it’s difficult to navigate. Why don’t we help remove barriers in our own lives and in patients’ lives? Often children aren’t up-to-date on their shots not out of refusal, but out of inconvenience or parental misconception. Why not provide text reminders when the booster for HPV is due? Why don’t clinics tweet or text times for flu shot clinics to all patients who need a flu shot (kids 6 months to 18 years of age)? Why not share doctors’ opinions through the smart phone? Why not make an app for that?
First, socioeconomic barriers and disincentives to vaccination should be eliminated. Even small copayments or administration fees pose substantial barriers for some families. Referral to a public health clinic is one option, but attending such clinics requires extra effort, travel, and time away from work — all disincentives to following through. Removing barriers to vaccination is an obvious first step to improving coverage. Some countries, such as Australia, have gone further, offering incentives for vaccinating children on time. Incentives can take several forms, including reduced insurance rates, tax rebates, or direct payments.
We have an opportunity to harness the tools of social media to affect real change and deconstruct barriers. Patients don’t only want more credible science, they want the truth from a trusted partner. The real story, the real facts. We patients want access to why/what/how to protect our children. Doctors need to be communicating online as a part of their day. We already know that parents trust the pediatrician more than anyone else when it comes to questions about vaccine safety. And we’ve known this for a long time. Dr Diekema hints at online opportunity here:
Fourth, clinicians, health care organizations, and public health departments must learn to use the tools of persuasion effectively. In The Art of Rhetoric, Aristotle argued that persuasion requires not only a reasonable argument and supporting data, but also a messenger who is trustworthy and attentive to the audience and a message that engages the audience emotionally. Data and facts, no matter how strongly supportive of vaccination, will not be sufficient to compete with the opposition’s emotional appeals.
There is a race to make a number of apps in health care. And I’m working hard to help. But we need an app now facilitating credible information on vaccines and personalized information in the palm of parents’ hands. I’m waiting for the day when we say, “Yes, we have an app for that.”
Liz Ditz says
I think there IS already an app for that…tracking immunizations I mean, but I think it was developed by anti-vaccinators. I’ll ask her about it, as I can’t find the reference.
PamB says
I think parents have reservations concerning vaccinating their children, because if their child has an adverse reaction, there is no place for them to turn as the vaccine makers are protected from law suit.
In addition, as a parent, I wonder why my infant is recommended vaccination such as Hepatitis B for example, when this vaccine series only offers protection from this disease for approximately 8 – 10 years?
When you also understand that a person contracts Hep B through unprotected sex or sharing dirty needles, one has to ask; how many toddlers are running around having unprotected sex? The answer is obvious… none. So why are we vaccinating our infants for un-needed protection that is not only expensive, but could present a medication reaction?
Wendy Sue Swanson, MD says
PamB,
Hepatitis B vaccine is designed to last a lifetime.
Here’s a nice Q&A response from CHOP vaccine education center addressing your question.
https://www.chop.edu/service/parents-possessing-accessing-communicating-knowledge-about-vaccines/vaccine-preventable-diseases/hepatitis-b.html
Q. Why does my newborn need to get a vaccine against a sexually transmitted disease?
A. The hepatitis B vaccine is recommended for newborns for a few reasons:
One of the most common exposures for infants is during passage through the birth canal of an infected mother. If mom is known to be positive, treatment and immunization of the baby is effective in controlling the infection; unfortunately, the test is not perfect and, before universal immunization, many babies did not get the necessary treatment. By giving the vaccine to newborns, those with infected moms are protected even if mom wasn’t tested or the test result was wrong.
Many people do not know they are infected, so others do not always know they were exposed. By giving the vaccine to young infants, they are protected if they are exposed.
Children who get hepatitis B are more likely to be chronically infected and less likely to display symptoms, so these children are not often treated which leads to liver failure or liver cancer, and in addition, continues to unknowingly spread the disease. The infant immunization program decreases the number of children growing up with hepatitis B.
Nanna says
Hepatitis B doesn’t only spread through dirty needles and unprotected sex. Please see below.
From CDC website:
Hepatitis B virus is easily spread through contact with
the blood or other body fluids of an infected person.
People can also be infected from contact with a contaminated object, where the virus can live for up to 7 days.
• A baby whose mother is infected can be infected at
birth;
• Children, adolescents, and adults can become infected
by:
– contact with blood and body fluids through breaks in
the skin such as bites, cuts, or sores;
– contact with objects that have blood or body fluids
on them such as toothbrushes, razors, or monitoring
and treatment devices for diabetes;
– having unprotected sex with an infected person;
– sharing needles when injecting drugs;
– being stuck with a used needle
– household contacts of people infected with hepatitis B,
– residents and staff in institutions for the developmen-
tally disabled,
– kidney dialysis patients,
– people who travel to countries where hepatitis B is
common,
– people with HIV infection
As you know most kids share toys etc. Things that they have had in their mouths, rubbed in their eyes or on their nose. I’d say there is NO reason to avoid the HepB vaccine.
Julie says
I am curious about mama doc’s opinion about when and if to do titer testing of your child? Mine will be five end of May and has all his shots but I am concerned now that so many schools have low vax rates if he is as protected as he should be. And what is the ideal vax rate for any school? 95%? Or does it depend on the individual vaccine? I have a call into my ped but wanted to get a run down on the pros and cons of these tests for her. If my son were to get a titer test and tested low, if that is the term, are boosters recommended? I already know of one mom friend who’s child came down with whooping cough depsite being vaccinated and it bought her many days in isolation with him, missing work and of course she was worried sick herself. Which leads to another question – if if my son did come down with, say for example, whooping cough despite being vaccinated, would the fact that he was vaccinated mean his case might not be as severe and lead to a quicker recovery? Maybe these questions are in another post or worthy of a new one from mama doc! (btw – my son will be starting kindergaten in the fall of this year and I understand his soon to be school has an opt out rate of about 6% – which isn’t broken down by any individual shot.) And are you considered opting out if you have all the shots but you don’t do flu or chicken pox? (We do flu mist every year and he’s already had his booster for chicken pox.)
Wendy Sue Swanson, MD says
Hi Julie,
You ask a series of questions that raise some important realities with vaccines.
NO single vaccine is 100% effective. That means, if you vaccinate 100 kids, not all 100 children will be protected from the illnesses the vaccine prevents. Most vaccines have an effectiveness over 90% in most populations when administered correctly. This is precisely why we rely on community immunization programs. The more community members immunized the less likely a child (vaccinated or not) will have an exposure!
Our fully immunized children may not be protected from all the diseases we immunize for (they may not respond) but we certainly don’t routinely draw titers in children who have normal immune function.
And yes, although a child may not be fully protected from a vaccine, partial protection is common with some. Varicella is a good example. Children who receive the shot who end up still getting chicken pox have a very mild case (about 5-10 sores) versus those children without the shot who may have much more severe illness/presentation (hundreds of sores, fever).
Does that help? What follow up post are you thinking about?
Julie says
Hi thanks for the reply! I am just wondering if, given the fact herd immunity is so important in maximizing vaccine effectiveness, should parents ask for a titer test to make sure their child doesn’t need a booster for any pariticular disease since herd particpation is low? How does a parent know if their child has normal immune function until it is too late meaning their child gets whooping cough despite being vaccinated? And in that case, if given a titer beforehand showed poor response to a whopping cough vaccine would a booster even help?
Jen says
Just today a friend posted that the school district called to say there is an epidemic of Whooping cough at Glacier peak HS in Snohomish. A few of the parents who commented were confused thinking once their kids were vaccinated at birth they were fine. I of course know since I had a baby 19 months ago that you and every family member who comes in contact with that child needs a booster to protect that infant. There definitely needs to be more education for the parents who want to vaccinate and don’t know they are missing something important
Wendy Sue Swanson, MD says
Hi Jen,
We immunize against pertussis with DTaP vaccine starting at 2, 4, 6, and 15 months. Then children receive a booster dose before kindergarten around 4-6 years of age. Then again a booster with Tdap at 11 years. Pertussis causes whooping cough. However, we know immunity to pertussis (the “p” in Tdap and DTaP) wanes from childhood which is why we are now immunizing all adults, especially contacts of newborns.
If any question if your child is up to date on their pertussis dose, contact their health provider! But remember, even fully immunized children can get Pertussis, so if you have any concerns, talk with your child’s doc.
Julie says
I know I asked my son’s school district what the vax opt out rate was for his school but I don’t think most parents think to ask or know why it might be important. I think we need a system similar to the restaurant system in California that grades according to adherence to health codes. It should be as natural a question to ask as asking about school material or lunch quality and teacher standards.
Wendy Sue Swanson, MD says
Julie,
I WHOLE-HEARTEDLY agree. The systems aren’t set up to “advertise” their high immunizations rates, although I think they should.
On a side note, we’ve been applying for Kindergarten for our son both in the public and independent school systems in SEattle. SO far, all of the independent schools I’ve asked DON’T publish immunization rates. I’m PERPLEXED!!! But have vowed to find out their exemptions before we select a school for our boys.
Julie says
Should herd participation continue to decline and subsequent disease outbreaks & deaths increase will we have to end up isolating the non vaccinated further aggravating the situation? Having worked for an insurance company any given institution’s vaccine rate is a “rateable” risk and I can see school/daycare etc. having to limit how many people they can take that want to exercise their right to not to vaccinate because of insurance-induced caps. Esp. if a death can be linked to a so called patient zero? (if that is the term) Can that be done? Can the originator of a whooping cough outbreak for example be determined?
Viki says
I remember seeing the breakdown by vaccination for my school district. It was 90% for most except varicella at 80%. I don’t think any school publishes their specific finding. For those of us who can’t afford private school, what are we going to do if our particular school has a low rate? I guess I could homeschool my kids, but our school is a neighborhood school. Those same kids will be at the park, mall, Y, scouts, etc.
Publishing vax rates per school can have the reverse effect. The Waldorff schools in Seattle have the lowest vax rates in the county, at 47%. According to the school director, their vax rate indicates a community of free thinkers who ask hard questions and make deliberate choices about how they raise their families. I’m curious to see if rates dip lower now that the Seattle PI has given the issue some publicity.
jonmcrawford says
Quick google search turns up:
https://market.android.com/details?id=com.smartware.mobile.android.vaccinationrecord&hl=en
or
https://itunes.apple.com/us/app/cdc-vaccine-schedule-adult/id320967054?mt=8
so apps do exist.
Wendy Sue Swanson, MD says
Hi Jon,
I agree there are apps for tracking personal health. There are not apps tracking community data/schools, etc. However, even the individual app are not interfacing with the medical record, sending alerts, and providing education. The CDC schedule is great, but many parents tell me how difficult it is to read and interpret.
I don’t have any patients who use these well and update them at shot visits. The apps I’ve seen replicate the paper imms record in ways but don’t step beyond. And I want collaboration between patient and doc and community and school.
Thanks for the links! Anyone use an app and like it/keep it updated/learn from it?
Tam says
Hi, I have a question regarding vaccines for adults with children. I had my son in 2007, so since it’ll be (5) years this October should I get a pertussis booster? How about other adults he is around all the time (grandparents-younger than 65, boyfriend, friends)?
I found the 2012 CDC Adult Immunization Schedule(https://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf) and Teen Schedule (https://www.cdc.gov/vaccines/recs/schedules/downloads/child/7-18yrs-schedule-pr.pdf) but I’m a bit confused as to how they should read, specifically on the adult chart.
Using the DTaP schedule, for example, it’s given in (5) doses bringing you to age 6. Then it’s given as Tdap between 11-12 years and ONE last vaccine (depending on pregnancy and being around infants) between 19 and 64 years–is that right? With a Td booster every (10) years. So, that all being said, if I gave birth in 2007 and was 28 at the time and had the Tdap vaccine, does that mean I don’t need another Tdap till I’m 65? The vaccine chart is so confusing!
I really want to update a chart for both my son and I so I will know my level of protection. I’ll keep checking this blog for updates on apps. And, the next time you see my son I should be using a vaccine app for both him and I!!
RooneyA says
I was wondering if you were discussing the need for an App to help parents track vaccinations, such as VaxTrak- (https://www.appolicious.com/health/apps/124120-vaxtrak-novartis-vaccines-and-diagnostics-inc) or if you were saying that there is a greater need for an app for educational purposes, that could help parents/relatives understand the importance of vaccines. Are there any apps out there that fill that niche?
Ginny Heller says
Thanks for this post Wendy Sue – Wanted to let you know that we are working collaboratively with DOH and Schooldigger.com to post yearly immunization rates for schools across the state! Stay Tuned!
Wendy Sue Swanson, MD says
Wonderful!! Please keep me posted, Ginny.