Pediatricians' Conditional Comfort With Alternative Vaccine Schedules

I had coffee with Dr Doug Opel last week to discuss his study about pediatricians and alternative vaccine schedules that published today. I learned a lot while we spoke. There is great wisdom in what he said (below in the interview & on video) that extends far past what he learned in the study.
Dr Opel is one of those genuinely authentic, kind people. The kind of person you meet and wonder, gosh if only I could be a fly on the wall when he’s making decisions for his kids or decisions for his life or decisions for his patients–I’d be so much better off. Not just because I’d see the answer, but because I’d have a front row seat while he asked the questions. He’s just remarkably thoughtful so there is no wonder this study illuminated some helpful observations.
Dr Opel and his colleagues conducted a survey of WA State pediatricians to find out how often they were being asked about alternative vaccine schedules and how doctors felt about it. Seventy-seven percent of pediatricians reported they are regularly being asked to use an alternative vaccine schedule. And in general, the majority of pediatricians (61%) are comfortable with alternative schedules but only for particular vaccines. Meaning that although pediatricians are okay with parents’ request to delay some vaccines (Hepatitis B vaccine or Polio) they are not comfortable waiting on others (DTaP, Hib, or PCV). The reason, Dr Opel suggests, is that pediatricians are unwilling to leave kids unprotected for potentially devastating diseases that still circulate in our communities.
In this interview, Dr Opel lends insight to the culture of concern about vaccine safety, how the changing health care environment has shaped how we ask questions in the exam room, and how the concern about autism and vaccines is simply emblematic of concerns about vaccine safety in general.
As I wrote last week, there are some pediatricians who refuse to see families who don’t immunize. Although some pediatricians draw those lines to protect vulnerable patients, most of us spend a great deal of our time in clinic discussing vaccine benefits and risks and work with families who request alternative schedules. And the majority of us (in Washington) are comfortable, at least in part, with alternative vaccine schedules. But as Dr Opel states, it’s a conditional comfort. It depends on which vaccine a family is asking to delay.
The hope from this study (in Dr Opel’s words) is that parents will know that, “Pediatricians really are here to work with you and to help you make these decisions.”  He also hopes that this will help spawn more research on alternative schedule safety, because he explains, “If parents are asking for these schedules frequently, we ought to know how safe they are.”
Here’s the majority of the interview I conducted with Dr Opel. You can also see snippets from the interview on video below.

Q: Why do the study?

Our collective clinical experience was that we were seeing more kids where parents were requesting an alternative schedule. We wanted to find out about WA state pediatricians’ preferences and comfort with parents’ requests for alternative vaccine schedules. We also know from other data in the state, parents are opting out of required school entry immunizations more now than they have in the past  We also felt it would be important to document whether [parents asking about alternative schedules] this is actually true. I think there are ramifications to the results. If parents are asking about alternative schedules frequently, we should know about their safety and effectiveness.
We wanted to get a sense of the collective experience of pediatricians. The more and more requests we see to deviate from the vaccine schedule of the CDC, the more we wondered about how pediatricians were responding.

Q: What did you find?

Deviations from the recommended schedule are occurring and pediatricians are responding that they are fairly comfortable with them. Overall, 77% of pediatricians reported that parents sometimes or frequently requested alternative schedules. Recent reports have shown on national level, that a significant number of parents are requesting this in other parts of the country. So the study confirmed our hypothesis that it’s a regular occurrence. Furthermore, 61% of pediatricians said they were comfortable using an alternative schedule if requested by a parent.

Q: In the study you wrote, “Parental acceptance of childhood immunizations is waning.'” Why do you think that’s true?

I think it’s got a complex and multifactorial root cause to issue of vaccine hesitancy. Three things contribute to it most:

1. The changing infectious disease environment. We don’t have a lot of the diseases we used to have around (no Small Pox, no Diphtheria, no Polio). Without them around, there is just a natural tendency for us to not be concerned about these or at least perceive them as less severe.
2. Changing health care environment. My father was a pediatrician and when he counseled families regarding recommendations, there was very little resistance to the recommendations he gave. Since that time (20-30 years) there has been a rise in consumerism that has affected health care, where parents feel empowered to take charge of their health care. Generally this is a good thing, but consequences are that parents feel compelled to not accept recommendations that their providers give them. And that might include vaccine recommendations. There are also more easily recognized limits to what modern medicine and science can do. Increasingly, science has given us an amazing achievement in medicine, and that is vaccines. But increasingly the thought that modern medicine can’t address many issues like substance abuse or obesity and that there are limits to easing the burden of chronic disease.  Modern medicine is perceived as being less able to do this and less useful and as we see these limitations, we feel that other places (like complementary and alternative medicine) that can address these problems. And this feeds into how we accept traditional medical recommendations.
3. How the media and the Internet have shaped this discussion. With the rise in consumerism in medicine, there are messages for the consumer and they come from mass media. And unfortunately those messages are anything but clear and straight forward. Rather they are very conflicting and misleading. Parents have to navigate this. A lot of misinformation and controversy is propagated. That doesn’t help hesitancy… in fact, it probably fuels it.

Q:  What will you do with the results?

Well, if parents are asking about different schedules for immunizations, it has policy implications. Also, the more that parents request schedules outside the CDC schedule, the more we need to know about how pediatricians are talking about immunizations and the more we want those that set policy to think about these conversations.

Q:  Before Dr Sears’ book, did parents ask about alternative schedules?

I think the publishing of Dr Sears’ book really popularized the notion that there are other schedules out there that are possible and that parents can request from the child’s pediatric provider. I think my sense is that it is a much more frequent request since his book, but it the study, we actually asked pediatricians who Dr. Sears’ book affected their willingness to use an alternative schedule. The majority said it didn’t affect their willingness. Before Dr. Sears’ book, I’m sure that there were some parents that asked their provider if there was something different that what was recommended by of the Center for Disease Control (CDC). Now, there are parents that bring that book into my office, under their arms. His book has been widely read.

Q: Do you think concerns about autism, that started in 1998 with Dr Wakefield’s false claim about MMR safety, affect parents today? Does it feed and breed safety concerns about known side effects of vaccines (like fever or rash)?

The concern about autism and vaccines is emblematic of parental concerns about safety in general. Autism is devastating. It’s every parents’ fear that their child won’t develop normally and be able to interact with them in the way they hope and dream of. Because it is such a feared outcome, it is a highest level concern that most parents talk about when they talk about safety. But it doesn’t mean that it is the only concern. You almost have to shed away that layer [concern about neurodevelopmental outcomes] and their concerns about very bad things, and then several other worries (rash or minimal side effect) can be addressed.

Q: Pediatricians were more comfortable about waiting on certain vaccines, Explain your thoughts about that:

Pediatricians responded they were comfortable waiting on some but not on others; pediatricians had a conditional comfort with waiting. The three they weren’t willing to delay or use an alternative schedule: DTaP, HiB, and PCV.  We didn’t ask them why they were less willing, but most pediatricians were unwilling to delay those. We thought the reasons that pediatricians were unwilling to delay was because these vaccines covered diseases that are still in active circulation (like pertussis that is currently endemic and we are suffering from an outbreak right now in Washington) and diseases that particularly have severe consequences for babies left unprotected, like meningitis. Also, there are severe consequences from the infections caused by the infections protected by  HiB and PCV vaccines. These are things that can leave children devastated.  I think this demonstrates reasonable judgment on the part of pediatricians. I think they are doing the best job they can when parents desire an alternative schedule. It really reflects this tension that providers are dealing with: The desire they want to respect a parents decision but also an obligation to protect a child’s health.
Pediatricians are standing firm on those vaccines that prevent diseases that children have a high risk of getting or  life-threatening diseases and potentially being more flexible on other vaccines and yet being less rigid on the overall schedule.

Q: You said to me that pediatricians are doing a good job. what do you mean?

61% of pediatricians said they were comfortable with alternative schedules. That probably reflects the fact that –what’s the alternative? Either they say I’m going to give the shot even if the parent is not comfortable, or they kick the child and the parent out of the practice. And then it is a missed opportunity…It reflects that providers are left in this position: I want to maintain a good therapeutic alliance with this parent and child, and I want to develop trust over time and help them understand the benefits of vaccines over time and so that I can potentially get this child immunized or partially immunized. Acknowledging that maybe we can be flexible with parents [as pediatricians], but also stand firm and  say, “Look, these 3 vaccines are crucial to keeping your child healthy.” This study reflects that pediatricians are doing the best they can in these difficult conversations but also trying to stand firm when they need to protect children from harm.

Q: What do you hope this study will do?

On a parent level, I hope it shows to parents that pediatricians really are here to work with you and to help you make these decisions. And I hope it also shows parents that doctors are trying to do what is best for their child as well.
On a policy level, I hope this study moves the conversation towards better understanding of the safety of these alternative schedule and how effective they are, if at all, are they more or less effective than the recommended immunization schedule. If parents are asking for these schedules frequently, we ought to know how safe they are.