My clientele base is largely made up of families who choose to selectively delay immunizations or avoid them entirely and several have stronger conviction about this issue, than even where they might birth their child. While I do believe a select number of vaccinations have their place, I am not an advocate for the current schedule, particularly the varicella vaccination and hepatitis B at birth for newborns born to mothers without the virus. I appreciate however, that an epidemiology perspective is vastly different than one I have when sitting on the couch listening to a very informed couple share their convictions and plans for the needs of their individual family.
The past few years I have noticed an increased push for vaccinations among adults, particularly pregnant women. The H1N1 vaccine was heavily marketed in the United States for pregnant women a few years ago, yet while visiting Ontario during the same season, officials there were stating the same vaccine should not be administered to pregnant women.
Each of our clients are asked during their initial consultation if they have an up-dated tetanus shot, if they receive an annual flu shot, and if they have had the hepatitis B series. This is the point at which most share their convictions regarding the issue. It would be my guess that only two clients I have consulted in more than five years in practice have shared that they opted for the flu shot.
The CDC has released their 2013 immunizations recommendations. This update can be found in the February 5th issue of the Annals of Internal Medicine and the February issue of the journal of Pediatrics.
The most notable change, among a few new updates, is the recommendation that pregnant women should receive a booster dose of the tetanus, diptheria and acellular pertussis (TDaP) vaccine during each pregnancy, preferably between the 27th and 36th week of pregnancy.
The rationale for the new recommendation is due to increasing reports of pertussis cases throughout the country and increasing number of deaths to the disease in children within their first two to three months of life. The CDC anticipates a final number of reported cases at approximately 35,000 for 2012 and a total of twenty deaths, although many cases of the disease go unreported each year.
Giving the pertussis vaccine to pregnant women later in their pregnancy exposes the fetus by transmission of the vaccine through the placenta, increasing their level of immunity once born. While it was not specified directly that fathers, grandparents and siblings should be vaccinated, it is certainly suggested as an optimal approach for preventing detrimental exposure to the newborn.
In 2001, experts from around the world gathered to analyze the state of pertussis and to evaluate immunization strategies. In 2005, cocooning was introduced, which is a proactive approach to preventing pertussis in high-risk populations, particularly neonates and infants less than a year. The Global Pertussis Initiative’s definition for cocooning is “immunization of family members and close contacts of newborns.”
The rationale is that if all newborn contacts are immunized against pertussis, the newborn would be cocooned or surrounded by these individuals and would be less likely to contract pertussis. Their own immunity would develop from the DTaP series by one year of age.
Pregnancy vs Postpartum Administration
Antibody response to a dose of Tdap in postpartum women occurs by day 14 and is suggestive of an immune response; however, this may not protect the neonate. Immunizing during pregnancy allows for passive immunity that protects baby at birth and helps to assure family members are not sick during the “window of risk.” This passive immunity however, only lasts a few weeks, which is why several DTaP vaccines are recommended during the first year, so that baby can remain protected.
Repeated administration with each pregnancy has raised concerned among many. A 2010 study addressed this issue among adolescents and young adults, although boosters were only every five years as opposed to the CDC recommendation for pregnant women to have boosters every pregnancy, many of which repeat every 18 months. Researchers found the five year booster to be well tolerated and highly immunogenic.
Declining the Vaccine
Once fully informed of the pros and cons of the vaccine, certainly clients have the option to refuse. It is important to keep in mind, that because more and more parents are refusing vaccines (5-6% increase each year), the vaccine-preventable diseases will increase in incidence and even some of those children who are vaccinated will contract the disease because no vaccine is 100% effective. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence. Another study, (Feiken et al., 2000) concluded that schools with outbreaks of a certain infectious disease had more children in attendance that had exempted immunizations than other schools. It was found that children who were exempted from immunizations were 22.2 times more likely to acquire measles and 5.9% more likely to contract pertussis when compared to those who were vaccinated. A similar study (salmon et al, 1999) found that the risk of measles was 35 times greater in unvaccinated than in vaccinated children. Another study (Parker et al., 2006) examined the 2005 measles outbreak in Indiana and found that 94% of the people who contracted measles were unvaccinated and 88% of those were under the age of 20 years. All parents should be aware of the increased risk of contracting measles and pertussis when requesting immunization exemptions and that each of you who choose to decline, likely associate with like-minded families who have also chosen not to vaccinate their children. Additionally, between the years 1992 and 2000, 12 out of the 15 cases of tetanus in children were in children who had not been vaccinated against tetanus (Fair et al., 2002).
Immunization schedules recommended by the CDC can be researched further here.