‘WE ARE SORRY FOR YOUR PAIN’
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Dr. Jane Finlay had measles as a child, but in a sense she was lucky.
She did not get pneumonia. She did not go deaf, nor suffer brain damage from encephalitis. She did not die.
“I had a high fever and photophobia, so I was in a dark room with a terrible cough,” she said. “Pneumonia and ear infections are quite common because measles suppresses the immune system and one in a thousand gets encephalitis.”
Today, Finlay spends a good deal of time persuading parents that they should not expose their children to any of those risks by shunning the MMR vaccine, which protects children from measles, mumps and rubella.
Yet, today, local B.C. health authorities are working to contain an outbreak of measles with 17 confirmed cases.
Finlay books a full hour for each family’s vaccine consultation at B.C. Children’s Hospital. Often, it’s not enough.
She sees more families every year because of a “trend to vaccine hesitancy.”
“These conversations can take a long time and sometimes you get into these circular arguments,” said Finlay, B.C. Pediatric Society liaison to the B.C. Centre for Disease Control’s immunization committee. “It can be exhausting sometimes, but it’s great when you can seal the deal with a vaccination.”
Parents — often well-off and well-educated — arrive having done extensive research online, where widespread disinformation about vaccines fuels their anxiety.
“Often the first thing they say is, ‘I’m not anti-vaccination, but I’ve done my research.’ And that research is usually from non-validated sites on the internet,” she said.
“Those sites can be very frightening.”
Some vaccine hesitaters and avoiders have world views that are hard to address in a typical 12-minute doctor’s visit.
A small number of fundamentalist Christians consider vaccines as an unwanted intervention into God’s will for their lives, while some Christian Scientists believe they can better manage their wellbeing with prayer, said Paul Bramadat, director of the Centre for Studies in Religion and Society at the University of Victoria.
But religious groups have shown they can adapt and revise their attitudes toward vaccines, he said in an email interview.
“It is a mistake to view religious objections to immunization as non-negotiable, even though leaders might present them that way,” he added.
Secular vaccine-hesitaters may take a “magical” view of the universe and their bodies and may view illness as something best managed through natural means, such as alternative medicine. Or they may harbour suspicions about the influence of pharmaceutical companies and the intentions of their government.
“Some may believe vaccines are actually part of a conspiracy to control their minds, fertility, or some other aspect of their lives and they may be misled by the concerns expressed or the cures promoted by celebrities,” said Bramadat.
The challenge for clinicians is to form long-term relationships with people whose views are not initially — or not ever — altered by evidence, he said.
“This requires some compassionate listening, and some curiosity on the part of the health care worker about how these doubts persist, and what the dominant health care institutions have done in the past that have contributed to these anxieties,” he said.
The information age has thrown up some real barriers to rational debate about vaccines.
Agents of the Russian government have amplified anti-vaccine sentiment through social media to erode people’s trust in governments in the West, in one case through more than 1,000 fake accounts, according to Forbes.
One of the favourite subjects for the Russian agents is a study linking the MMR vaccine to autism by Andrew Wakefield, published in the British medical journal The Lancet.
It has long since been debunked as dishonest, unethical and irresponsible.
Nonetheless, it has led to a drop in vaccination rates and continues to fuel vaccine hesitancy almost a decade after it was retracted.
“How many children have died from what Andrew Wakefield did?” Finlay asked. “Look at the number of measles deaths in Europe or the Philippines, it’s thousands of children. It’s horrifying.”
While multiple studies over the past 15 years have debunked a vaccine-autism link, they appear to have little impact in the maelstrom of social media.
A large-scale Danish study published earlier this week found the MMR vaccine did not lead to higher rates of autism among 657,000 children born between 1999 and 2010. In fact, immunized children were seven per cent less likely to be diagnosed with autism.
Will a new study reassure wary parents? Probably not.
COMPLEX DENIALS
The reasons some parents aren’t vaccinating are complex.
“There is not going to be one public health message that will address low vaccination rates,” said Julie Bettinger, a UBC professor and researcher at B.C. Children’s Hospital’s Vaccine Evaluation Centre.
“The reasons people in the Downtown Eastside aren’t vaccinating are likely to be very different from those in West Vancouver and one message just isn’t going to work.”
The real pixie dust for overcoming vaccine fears is a long-term bond between doctors and their patients, she said.
Finlay says the conversation with hesitant parents is made easier if the doctor has already helped their child through an illness.
“You have to develop a trusting relationship and sometimes that takes five minutes, with others it takes multiple visits,” she said.
Concerns are overwhelmingly about safety and parents have to believe that the threat posed by the disease and its complications are worth the negligible risk of the vaccine.
“I was concerned about the MMR vaccine until a family friend that I greatly respect explained the hard number risk comparisons side by side,” said Nicole Huska, a B.C. mother of three.
“I (also) was skeptical about the need for chickenpox vaccine until I spoke with a public health nurse,” she said. “When she explained that more and more people are getting knock-on skin infections if they get the chickenpox, we went with the vaccine. Also, the shot decreases the chance of getting shingles.”
Huska was initially put off by the response she received to her questions.
“When I had my first daughter, I was 25 and the answers I was given by the health nurses then were mediocre, like they disapproved of me having concerns,” she said. “Now they’re much better at having the paperwork on hand and ensuring what they call ‘informed consent.’”
Some parents worry their children will be more susceptible to the illness if they get the vaccine or that vaccine additives are a hazard. They won’t and they aren’t, experts say.
“Some parents are so afraid of MMR they ask whether they should take their child to a measles party, where one child is already infected and the others are brought in to purposely get exposed,” said Finlay. “People used to do it with chickenpox to just get through it as soon as possible.”
In vaccine counselling, she takes on their concerns one by one, and if the parents are persuaded, Finlay is ready to give a vaccine on the spot.
“Oftentimes parents will accept some vaccines, so then it becomes a negotiation about what they will accept,” she said. “It’s rewarding, though, because I might have saved a life.”
The relative rarity of vaccinepreventable diseases such as measles has hobbled the public health debate about vaccination, as living memory of the horrifying consequences of these illnesses fades over time.
Few young parents have ever seen a case of measles. Nor have many young doctors.
From the mid-1920s through to the introduction of the first measles vaccines in the 1960s, between 30,000 and 83,000 cases were reported each year in Canada.
Between 2002 and 2013, the annual number of cases ranged from six to 752. In 2014, there were 433 cases in B.C. alone, most of them at a single religious school in the Fraser Valley, according to the Public Health Agency of Canada.
DEATHS WORLDWIDE
About 110,000 people die each year from measles worldwide, most of them children under five, according to the World Health Organization.
Outbreaks in B.C. in recent years have been associated with travel to Pacific Rim nations and to Europe, where anti-vaccination sentiment runs high and recent outbreaks have infected tens of thousands of people.
When the disease flares up, some parents rush to get their children vaccinated as the fear of an extremely rare vaccine reaction is overcome by the real threat of infection.
Since measles cases developed in southwestern B.C. in January, more than 17,000 of MMR vaccines have been requested in the Vancouver Coastal Health, Interior Health and Vancouver Island regions.
“That’s a dangerous strategy, because the vaccine can take a couple of weeks to take effect,” said Finlay. “It’s so contagious. When it’s airborne, it goes down corridors and stairwells.”
Canada has a target of 95 per cent immunization, which is required to confer so-called “herd immunity” where so many people are immune that the virus has difficulty spreading through the population.
Vaccine avoidance is often associated with religious conviction, but wealth, poverty and attendance at non-religious private schools also appear to be associated with low vaccination rates for a host of diseases, according to a study by Bettinger published in the journal Vaccine Reports.
The City of Richmond had the highest vaccination rate in B.C. for kindergarten-aged children, while highly affluent West Vancouver and Bowen Island together have a vaccination rate 30 per cent lower than Richmond’s.
Some schools in East Vancouver’s least affluent neighbourhoods have vaccination rates for measles between 50 and 70 per cent, according to Vancouver Coastal Heath.
“In some cases, these figures may reflect weak record-keeping and it may be that the parents haven’t had good access to vaccination services,” said Bettinger.
Whatever the reason, these rates are too low to confer herd immunity, she said.
In the Coastal Health region, 83 per cent of kindergarten students have been vaccinated for measles.
Ontario students must be vaccinated against nine diseases, including measles, to be allowed entry to a school.
The province has 92 per cent vaccine coverage with only two per cent of school-aged students granted exemptions.
According to Coastal Health, vaccination rates from 27 to 43 per cent have been recorded among kindergarten-aged children in alternative programs such as Waldorf and Montessori schools.
Providing your child’s vaccination records to schools is voluntary in B.C., but that is about to change.
Health Minister Adrian Dix is setting up a vaccine registry to collect the vaccination status of every child attending public and independent schools in B.C. starting this September.
“Some people just want more information, and an even larger number are people who have busy lives and may have fallen through the cracks,” he said.
“They aren’t necessarily opposed to immunization, they have just somehow missed out,” he added.
Dix isn’t keen to make vaccinations mandatory for school attendance but, following the example set in Ontario, he is prepared to make it much harder to opt out for philosophical reasons.
Schools will be required to collect vaccination records for the ministry of every child registered for school, which will fill in gaps in record-keeping and provide an opportunity for health care providers to offer counselling and vaccines to families who haven’t sought vaccination, said B.C.’s public health officer, Dr. Bonnie Henry.
Starting this year, records will be obtained or updated for every student.
After that, records will be required when a child starts school or changes schools.
Knowing which students aren’t protected allows schools to act quickly when these diseases flare up and to send unvaccinated children home until it is safe for them to return, she said.
With so many measles outbreaks in the world, it is inevitable the virus will be introduced again and again by people returning from trips abroad, she said.
“These large outbreaks in Europe and elsewhere are a reminder of what can happen if we aren’t vigilant,” said Dix. “We really want to avoid a repeat of what happened in 2014.”
Once the vaccination records are obtained, public health services can follow up with parents to make sure children have the opportunity to get vaccines they are missing.
About half of immunizations are given by family doctors and much of the balance are provided by public health nurses, in community clinics and school-based immunization programs.
Henry estimates that up to 30 per cent of the province’s 600,000-plus school-aged children have gaps in coverage.
“I’m very happy about the recent spike in immunizations, but we need to make a sustained effort over time to approach 95 per cent coverage,” said Dix.
“It’s not about making new rules, it’s about making sure everyone has the opportunity to be immunized.”