harvard vanguard medical associates


Five Downsides Of Spacing Out Your Child’s Vaccines

It seems like the perfect compromise. You want to protect your child from illness, but you’re leery of vaccines. So you ask your pediatrician to “space them out” — to give no more than one or two per visit, or per month, or to skip a few for now.

You’re not refusing the couple of dozen shots recommended for the first two years of life, you’re just….delaying. And you have plenty of company: Parenting Websites teem with descriptions of the alternative vaccine schedules that mothers and fathers invent (examples here and here) or borrow from a popular book. So what could be bad?

Well, several things, say pediatricians and vaccine experts concerned about the widespread vaccine-spacing phenomenon. To begin with, they say, the premise that a simultaneous volley of shots could be too much for your child’s immune system needs to be put in context: Children’s immune systems are exposed to a constant barrage of foreign proteins, and vaccines are engineered to produce as focused an immune response as possible.

More broadly, here’s the big picture from Dr. Allison Kempe, a University of Colorado School of Medicine professor of pediatrics who researches popular resistance to vaccines:

“It’s a very small subset of parents who totally refuse vaccines,” she said, “but it’s an increasing number, and a much higher number, that are asking to space them out. And that results in the child being unprotected for longer periods of time. It may result in outbreaks of disease and it may mean that because the vaccines are spaced out, the child doesn’t actually end up getting all of them because it involves coming in for so many appointments.”

“The other thing is that I don’t know whether it’s a lot more traumatic for a child to constantly be coming in for a shot. All those things are unknown. And there’s absolutely no science behind it, that’s the biggest thing.”

Dr. Ben Kruskal, a vaccine expert and director of infection control at Harvard Vanguard Medical Associates, offers a similar view from the pediatric trenches. I’ve broken down his concerns here into five parts:

1) Prolonged Vulnerability

“The most potent reason why spacing is problematic is that the more you spread things out, the more time kids are vulnerable to infections they could be protected from,” he said. “The extra time of vulnerability you’re adding to a child’s life is really quite considerable, and that’s not a trivial thing.”

(Particularly because, as CDC vaccine-communication expert Glen Nowak points out, the diseases that vaccines can prevent are particularly dangerous when they occur in the youngest children.)

2) Potential Added Trauma and Fear Continue reading

Pediatrician’s Dilemma: Drop Families That Refuse To Vaccinate?

A young boy is vaccinated against MMR in Scotland in 2007.

Question: If parents refuse to have their children vaccinated, is it ethical for a pediatrician to respond by refusing to be their doctor?

Answer: That’s under continuing debate. But a new report finds that 25% of pediatricians do “dismiss” anti-vaccine families from their practices.

Question: Readers, what do you think? And please let us know if reading this post changes your opinion at all.

Dr. Ian Sklaver, an experienced pediatrician at Garden City Pediatrics in Beverly, welcomes parents’ questions about vaccines. If they want to spread out the shots so not as many are given at one visit, he’ll do it. He wants them to be as comfortable with vaccines as possible.

But if a family refuses crucial vaccines and will not be budged, “then I suggest to them that I am not the right doctor for their family,” he said in an e-mail. “I would not feel like I was providing good care to someone who was refusing immunizations. I certainly would try to change their minds, but I have had to ask a handful of patients to leave.”

“If the overwhelming abundance of scientific information and my own strongly held beliefs do not convince them, then I have to let them know that I think their decision is leaving their child at risk of grave harm and I would not want to be a part of that decision,” he said. “I also have to consider the other children in my waiting room who would be exposed to the unimmunized child, putting them at risk as well.”

A new study out this month finds that Ian is far from alone. The national survey of several hundred pediatricians found that a substantial minority, about 25 percent, do always, often or sometimes “dismiss families” from the practice if they refuse vaccines in the “primary series” — the basic vaccines including polio and diphteria.

Dr. Allison Kempe

It’s no easy decision. “The bottom line is that it really is an ethical dilemma for pediatricians,” said Dr. Allison Kempe, lead author of the paper in the American Journal of Preventive Medicine. “I can tell you that personally, it’s an ethical dilemma for me.”

The issue of vaccine refusal has bedeviled pediatricians for years, and persuading reluctant parents to vaccinate has become a huge time-sink in many practices. No matter how many scientific studies come out exonerating vaccines of any role in the autism epidemic and touting the good they do, many parents continue to fear the shots.

Dr. Kempe’s data, gathered in 2009, found that vaccine refusals appeared to be on the rise: nearly one-tenth of pediatricians and family practitioners reported that 10% or more of parents refused at least one vaccine in a given month. Almost 80 percent report at least one refusal in a typical month.

So at what point can or should a pediatrician ethically draw the line? Continue reading

Q&A: With More Measles Reported, What Should Adults Do?

(To keep tabs on the latest local reports of measles cases in real-time, you can click on the Massachusetts Health Alerts box in the lower right portion of this page.)

This week, Massachusetts public health authorities confirmed six new cases of measles. That brings the total number of cases of the highly contagious disease up to 11 for the year. We all know that our children should be vaccinated against measles, but what about adults? Do we need boosters of some sort? How much risk are we at, and how much effort should we expend to protect ourselves at this point?

Dr. Ben Kruskal

I spoke this morning with Dr. Ben Kruskal, director of infection control at Harvard Vanguard Medical Associates and an expert on vaccines.

Q: So what should grown-ups be doing about measles?

A: We’re not quite at the point yet of an all-out effort for adults or kids. But what I would say for adults is that the most important thing — and unfortunately, not an easy thing — is to ascertain if they are immune.

For most of us who’ve grown up in the US, if you were born before 1957, you’re generally presumed to be immune because measles was circulating so much back then that just about everybody got it. And once you’ve had it, you’re immune.

For people born after 1957 who’ve grown up and gone to school in the US, the vast majority have been vaccinated because of school requirements.

For people who haven’t grown up in the US, they should make sure they’ve had two doses of measles-containing vaccine (MMR or just measles vaccine).

For people who don’t have a definite history of their vaccinations, there’s a simple blood test that can be done to demonstrate whether they’re immune. Insurance generally covers the test, and clinicians can generally order it without an office visit. If the blood test is ever positive, immunity is lifelong—the test need not be repeated.

One footnote: From 1963-1967, there was a “killed virus” vaccine used in the US and some parts of the world that was not very effective. People who were immunized with that vaccine may benefit from the blood test.

You can get measles by walking through a room where someone who has it was present an hour earlier.

Q: Would you recommend going to the effort of the blood test mainly for people at particular health risk?

I don’t think the magnitude of the outbreak is big enough to do it for everybody.

On the other hand, measles is so contagious, and a bad enough thing to get, that I don’t think it’s easy to focus on a subgroup that’s at high risk. Measles is probably the single most contagious infection. You can get measles by walking through a room where someone who has it was present an hour earlier. Continue reading