Dr. Rachel Orscheln presents on trends in vaccine coverage, common parental concerns regarding immunizations, clinical presentation and diagnosis of vaccine-preventable diseases seen infrequently in the US, and strategies for combating vaccine hesitancy.
Well, thank you all for joining us today to talk about vaccinations and vaccine refusal is a major problem in pediatrics. So, uh, I have no disclosures. So, uh, the World Health Organization actually lists vaccine hesitancy as one of the top global health threats, and I think we've seen recently the impact of vaccine hesitancy in terms of resurgence of infectious diseases. So, if you look at the number Of kindergartners who either have medical or non-medical exemptions from vaccinations in the United States, you can see that in Missouri, we actually exceed what is expected for the level of exemption, um, up there at the top at over 3.3%. Illinois is a little bit under that. And if you look at Missouri data by year, you can see, starting with 2019 and in, uh, going forward through 2024, we've had an increasing number of Children who have vaccine exemptions. And, you know, some of these are medical exemptions. These tend to say static, static over time, but religious exemptions or non-medical exemptions have been increasing over time. Um, it should be noted that there isn't a major religion that actually forbids vaccination. There are some that have a more nuanced approach to it, but there isn't a major religion that refu or that, um, refuses vaccinations as a whole. Um, if you look at the number of states in the country or states and jurisdictions where we could not achieve greater than 95% coverage with MMR, you can see that is also increasing over time, starting with the COVID-19 pandemic. We see an increasing number of jurisdictions where we will not be able to achieve that level of coverage for measles vaccine, which we think is necessary to prevent outbreaks. At a local level, you can look. At Missouri data for the number of kindergartners that are fully imm immunized by year, and again, you can see both for public and private schools, the numbers of kindergartners who are vaccinated um by year has decreased every year. So we are seeing, you know, in some ways this has been a tide that's been rising before the pandemic but was exacerbated by the pandemic, where more and more people are questioning vaccinations and actually refusing vaccinations for their children. Children and that can result in a significant number of school age children who are susceptible to vaccine preventable diseases. If you look at our more, uh, local data for Saint Louis City and County, uh, we continue in the county to have fairly high rates of vaccination among our school children, and that's been stable over time in the city. Um, it's a bit lower, and there can be variable factors that can affect that, um, and we can talk a little bit more about that. But the upshot of a. All of this is that we continue to see outbreaks of infectious diseases in areas where vaccination is reduced. So I've been looking at the data that the CDC puts out every week on the number of cases, and every time I update this talk, uh, the number of cases has jumped by several 100. So currently we have 14 outbreaks occurring in the United States, and an outbreak is considered 3 or more linked cases. 93% of the cases occurring in the United States right now are outbreak associated, and the largest outbreak is in West Texas and New Mexico, and this is largely confined to a Mennonite population that again doesn't uniformly refuse vaccination but has more uh resistance to vaccination overall in the community and so much lower rates of vaccination. Uh, the current case count in Missouri, we've had 2 cases in Missouri. One of those cases was a child who had just come from Mexico, and that's a typical um situation that we see in the United States every year, where we see cases imported. Thus far there have been, um, of the cases that have been reported, uh, 13% have been hospitalized, and there have been 3 deaths. Um, the number of deaths that we've seen so far probably is an indication that we have not ascertained all the cases that are happening because that's a fairly high um case fatality ratio based on the number of cases we know. Um, in terms of the people who are being infected, um, 96% of the cases are unvaccinated or have an unknown vaccination status. Um, in terms of where measles is occurring in the United States, again, primarily, this is focused in Texas and New Mexico with the vast majority of cases occurring in that West Texas border that you can see here, but we are seeing cases occurring in various other locations, again, including Missouri, but most states are only having a handful of cases as compared to where the outbreak is occurring. So if you look at measles cases by year, we tend to see periodically surges in cases. I think it is likely that our case count this year is going to, uh, eclipse what we have seen in recent years. Um, when we do have outbreaks, which occur periodically, they often occur in groups of people that are close knit and have lower rates of vaccination. So in 2014, we saw a large number of cases, several 100 cases occurring in an Amish community that was imported by an Amish missionary who went to the Philippines, came back to this um community with low vaccination rates, and there were over 300 cases. In 2015, there was a uh a child that visited Disneyland, and then that uh resulted in measles cases all over the country. In 2017, we had an outbreak occurring among Somali individuals who had um vaccine resistance related to being influenced by the anti-vaxx community, and there was a concern that they had learned that vaccinations were associated with autism, so they refused vaccinations, and as a result saw a number of cases. And then in 2018 we saw an outbreak among Orthodox Jewish individuals. There are many countries in the world where there is high measles transmission, and the rest of the cases that occur in the United States each year are typically imported cases, and they're often just a single case of a person who was susceptible to measles who traveled and then comes back with measles. But that can spark a forest fire when that person is a part of a close knit community with lower rates of vaccination. So, just to talk a little bit more about measles, since it's so front of mind right now, we know that measles is a highly infectious disease in a susceptible population, when there's an exposure, about 90% of individuals will be infected, and the typical incubation period is between 1 to 2 weeks, but can be a. To 3 weeks, um, transmission occurs, unfortunately, when the illness is fairly non-specific, fever and respiratory symptoms, and a person is infectious from 4 days before the onset of the characteristic rash, until 4 days after that rash has developed. I like this graphic because it gives us uh a sense of how the symptoms develop. Fever is often the first symptom, non-specific, and then you will see respiratory symptoms including cold symptoms, cough, conjunctivitis, uh, if you're a careful examiner, you may see these whitish gray spots in the mouth that develop, uh, the colic spots, I've never seen them. Uh, and then the rash that develops. The rash is described as like hot coffee is being poured on the head, so typically starts, the hairline, spreads down the face into the trunk. Maculopapular erythematti, um, can have a different presentation depending on the skin tones. And I don't know if you can see, I, I can barely appreciate the colic spots in that picture of the mouth. So in terms of managing measles, if you think you have a patient in your office, we want to immediately isolate that person. If a negative pressure room is available, that's the ideal location. Uh, if you have a patient that shows up in clinic and, uh, there's a high suspicion you want to keep track of who is in the waiting room and who takes care of that patient in case there is a need to administer post-exposure prophylaxis, healthcare workers should wear N95 mask, and the patient should wear a mask as well. If there's not an N90 or a negative pressure room, then putting a patient in a room, um, uh, putting a towel, a wet towel under the door has been. to keep air flow from going in and out, um, and if the patient needs to be transferred to another location like an emergency unit, it's important to let people know ahead of time that the patient is coming. Once a patient with active measles has been in a room, that virus can remain in the room for about 2 hours. Now, there's some variability depending on the air exchanges, but that room should be left empty for 2 hours after the patient leaves the room. In terms of measles diagnosis, um, a variety of tests are available, and it depends on the sensitivity of the test, depends on when the patient is in their illness. Um, you can get IgG and IGM, um, which can, uh, be present in the blood after, um, um, the rash has developed. You can often detect IgG and IGM. Uh, uh, PCR testing can be obtained from the blood NP swab and urine, and again, testing is most sensitive on day 1 to 3 of the. Rash. Um, any testing that's obtained, we should generally be talking, um, if you're in the St. Louis area, calling Children's Direct and the infectious Disease, um, division can help to coordinate testing. In order to have testing done with the state, we do need approval from the state. And so the state health department is on call 24 hours a day to help with making uh, testing and treatment decisions, and then they can also facilitate the testing. Um, I was in contact with the provider who took care of the. Child in southern Missouri who was diagnosed with measles, and they had testing results available within 24 hours. They had a very rapid turnaround from the time that they suspected measles till that test was available. So working with the state on that can be really helpful. There are commercial labs that have testing available, Quest and LabCorp, and so again, if the, uh, if there's a high degree of suspicion, but the, uh, the state is unwilling to perform the testing, there are other, uh, venues by which testing can be obtained. There is no specific treatment for measles. We do supplement, uh, children with vitamin A, which has been shown both in the US and other countries to reduce complications of measles. Um, so measles can be a serious disease. I think we're aware of that based on the fact that we have two otherwise healthy children in the United States of America who died from measles this year. So about 1 in 5 people will get hospitalized for measles, uh. 1 out of every 20 children will develop pneumonia. 1 out of 1000 people will develop encephalitis, and between 1 to 3 per 1000 people with measles will die. There's also a late complication of measles that happens, you know, 8 to 10 years after called subacute sclerosis pan encephalitis, that is a progressive neurological disorder that has no known treatment and almost uniformly leads to death. Very young infants, pregnant women, but anybody can develop this, but uh very young infants who get measles and pregnant women are at the highest risk for developing SSPE. So, fortunately, we have a preventative measure for measles. So children should receive vaccination at 12 to 15 months and then 4 to 6 years of age. Um, children who are traveling internationally should receive a dose, um, if they're over 6 months of age, uh, and, um, then should complete their series. Currently in the United States, there's no recommendation for accelerating our vaccine schedule. There is a potential for reduced. to vaccines when they're delivered early, and so it is definitely beneficial for a child to receive at least one dose after 2 years of age. So at this time where we're not having a local outbreak, um, I know there are a lot of families that are asking about early vaccination, but the risk of measles in our community remains very low at this time, and so we're not recommending changing our vaccine schedule based on we'd like to have the best efficacy of the vaccine when it is administered. Um, healthcare workers should all have two doses of the MMR vaccine. Um, people who were born before 1957 are assumed to be immune, and people who, um, don't have a documented live vaccine or serological, um, confirmation of immunity should consider getting a vaccine. So again, vaccine is highly effective. 93% of people will respond to one dose of the vaccine, and then 97% of the population has positive antibody testing after two doses of the vaccine. And again, no current recommendation for um doing any um additional vaccines outside of people who are traveling internationally. We do have post-exposure prophylaxis and then uh the uh most recent exposure that we had at the St. Louis Aquarium, we did administer post. Exposure prophylaxis to unvaccinated infants who were exposed. Um, if you have a child over 6 months of age and they're within 72 hours of the exposure, you can give an MMR, um, or if they're outside of that period, you can give IGIM to infants up to 12 months of age, and then after that we give IVIG to anybody who's not immune, or people who are immunocompromised, or people who are pregnant and have a known exposure to measles. So we know that vaccines highly effective. If you look at, um, data, um, that is available, you can see that over 60 million deaths have been prevented, uh, between 200 and 2023 with vaccination against measles, so highly effective, um, but the problem we have is that vaccines are so effective, um, but we do rely on people taking these. Vaccines in order for them to be most effective. When we have high vaccine coverage, we see a reduction in these infectious diseases, and then these things are no longer front of mind for people. So our reduction in disease has resulted in increased complacency about vaccine preventable diseases. People no longer fear these diseases, and instead they fear what they hear in the media, and so we get a reduction in vaccination uptake in the community. So there are a number of different parental prototypes for um with attitudes toward vaccination. There are people who are immunization supporters, they're very, they are likely to um have knowledge about vaccines, have strong feelings about having their childhood or child vaccinated, and have a good relationship with their healthcare, um, provider and strong trusted health. Care system. And then there are families that will go along with vaccination. They may not have a lot of knowledge about it, but they'll certainly do it. Um, and then there are people that have more concerns that are likely to go along with vaccination, and then there are people that have a lot of concerns. They may have personal family experience, they have heard things, they're sitting on the fence, uh, and, and they. Require a lot of energy, um, to talk about vaccinations. And then there are people who refuse vaccination. They often have fixed health beliefs that are difficult to, um, meet with data. Um, you know, often they have beliefs about things that are just, frankly untrue, and it's very hard to, um, sway them in their vaccine decision making. So there are a number of determinants of vaccine. Um, hesitancy. We certainly have a lot of information on the in the media and not necessarily good information. People can get information from a variety of sources that, um, can put out information that's very scary, and parents don't wanna do anything that will potentially harm their, um, child. And so depending on what type of information they're, um, reading, they may have a. A lot of concerns. They may be listening to certain influential people, um, people on TikTok. Uh, and so they may have concerns based on that. There certainly are religious groups that have lower uptake of vaccination. Um, there are certainly cultural things that may be at play. Um, we know that not everybody has the same access to vaccinations, and that can, um, impact their Ability to get, um, vaccines, um, certainly how those are paid for is really important. Uh, there can be barriers in terms of travel, and certainly people have, uh, perceptions about the pharmaceutical industry, and they have, um, inaccurate beliefs about how doctors and healthcare providers interface with the health, the pharmaceutical, uh, industry. We don't get paid by, uh, you know. To give more vaccines, um, and certainly there are individual things, you know, I, I'm sure all every one of us has a family member who says, well, I got the flu shot and I, uh, and I got the flu. I think that was my grandmother's reason for not receiving the vaccination. Um, so they've had personal experience with vaccines. They may have heard about someone who had an adverse event related to vaccination or something that they tied to that vaccination. Um, they may have, you know, overall lack of trust of the healthcare system based on their own personal experience or historical, um, treatment of, uh, their, uh, themselves or their community by the healthcare system. And again, this sort of perceived risk versus benefit from vaccines, that's very personal. Um, and then people may view either immunizations as a social norm in their community or as something not needed and harmful. And then there are beliefs that are very specific to vaccination, and we know we've seen this in the COVID-19 pandemic where people like, they'll take all the vaccines, but you mentioned the COVID vaccine, and they believe it's a conspiracy. So people can have fixed beliefs about one vaccine. There's many people who will accept all routine childhood vaccinations, but not the influenza vaccine. Um, they may not be happy about how the vaccine is administered. Um, they may have questions about the cost of the vaccine or the schedule. Or are we giving too many vaccines? Um, and I think what I've also seen is there's variability in the recommendation for vaccinations among healthcare providers. So, you know, certainly many pediatricians recommend all routine childhood vaccinations, but I've had families, you know, tell me that their, their healthcare provider didn't recommend COVID or didn't recommend the flu shot for them, um, or had, you know, recommendations that were outside of what we would recommend based on the CDC and ACRP. So, um, there is a big cost to vaccine refusal. Certainly when we have an outbreak in our community that has a significant financial drain. So in terms of the outbreak in New York in 2018 and 2019, that outbreak was estimated to cost $8.4 million of taxpayer money. Certainly, um, individuals will have a cost to them when they miss time off from work. You know, this can even, uh, be for kids who are just exposed. So if you're exposed and non-immune, you must be excluded from school for a period of time. Sometimes that's several weeks of exclusion, that comes at a cost for people who rely on the school for the childcare. There can be payer cost. It's estimated that for every $1 you spend on vaccination, you will actually save $3 in cost. And so if you multiply that across the population, that's a significant amount of money. Um, and I think for pediatric practices, you know, I'm preaching to the choir here, but there's a significant cost in terms of the time it takes to counsel families who are vaccine hesitant, uh, the loss of value-based compensation. So if you're being, uh, judged based on how you comply with, um, getting all your patients up to date on vaccination, there could be a loss of compensation based on that. And then if you have an uh an exposure in your office, there's a significant cost in terms of time and personnel that it takes to um look for exposures in your healthcare setting. So, um, you know, families have lots of questions about immunity, and one is, well, if my child isn't vaccinated, what about, aren't they protected by everybody else being vaccinated? And so, you know, I actually had a mother say that to me, I was like, well. Um, hmm, yes, it's, you know, as long as your herd is well vaccinated, uh, I guess you're, you're fine. The problem is people tend to co-localize with other people who have resistance to vaccination. So we know that herd immunity or community immunity is the resistance of the group to the attacks by an infectious disease based on a high level of immunity within that community, which means that susceptible individuals, if they are in the community, such as young infants, are less likely to come in contact with. Um, an infectious person, and we rely on herd immunity to protect people who can't be vaccinated. So that includes young children or people with immunocompromising conditions. Um, but, you know, if we have a decline in the number of people who are vaccinated in our community, that means that people are more susceptible, and we know that most vaccines aren't 100% protected, so we really rely on the chances that we won't encounter infectious disease to keep all of us safe and healthy. So, you know, the degree to which you need the population uh vaccinated depends on how infectious the uh agent is that you're dealing with and also how effective the vaccine is. And so it's estimated based on the infectiousness of measles and the number of people and the um and the sort of effectiveness of the vaccine that we need about 96% of the population vaccinated to prevent outbreaks. So we see that when there are exemptions from vaccination, non-medical exemptions, that we see outbreaks of infectious diseases, and that's been illustrated in this most recent, um, measles outbreak. There was a study in pediatrics a number of years ago that looked at non-medical exemptions for vaccination and outbreaks of pertussis, and this took place in California where they geocoded non-medical exemptions and also then the, uh, the pertussis outbreaks. And what they Found in this study was that they saw a dramatic increase in non-medical exemptions. So the rates of non-medical exemptions tripled, um, when they compared 2000 to 2010. And in some areas, the non-medical exemption rate was 84% in some schools. Uh, and again, we need high rates of vaccine coverages, particularly for things like pertussis to prevent outbreaks. And what they determined in this study was that they could look at a map and they could overlay the. Rate the high rates of non-medical exemption with the outbreaks of pertussis. Now we know that pertussis occurs in our community as well, but when you see these big clustering of cases of pertussis, it's often in areas where there is increased non-medical exemption, and this was demonstrated in, I thought this was a really good map looking in Michigan again, clustering, time-based clustering of non-medical exemptions and cases of pertussis occurring in Uh, Michigan. So it really matters what your herd is. So you can see if you're in the herd over here on the, except the right or the left, uh, where a lot of people are susceptible, you're gonna see a lot of cases, and even when there are many people that are susceptible, um, in a population, even if you have part of The Populations that's vaccinated, you will see lots of cases of infectious diseases, but really requires this critical level of people being vaccinated to stop the spread of infectious diseases because you reduce the chances that any person will encounter an infectious individual. So one question that also comes up is, why do we need to keep vaccinating for things that are no longer seen in the United States. So I'll bring up the case of diphtheria, which I, you know, I was first making these slides a number of years ago, I'm like, what is diphtheria anyway? You know, I, we don't see this, uh, but it's a, you know, bacterial infection that causes. A respiratory infection can cause these pseudomembmbranes that can actually obstruct the upper respiratory tract and can cause other problems like uh myocarditis can be treated with antitoxin and um antibiotics, but death occurs in about 10% of people, and the vaccine is highly effective. In the former Soviet Union after the breakup of the Soviet Union in the late 1980s, vaccination rates fell in that country, and there was an absolute explosion in diphtheria cases. So in 1991, there were about 2000 cases, and then just eight years later there were over 200,000 cases with 5000 deaths. So diphtheria actually made it into the Guinness Book of World Records as the most resurgent disease. So we've seen in places where Um, vaccination rates fall substantially, these infectious diseases haven't been eliminated, and they will be ready to make a comeback if we let our guard down. So, yeah, some people will say, do vaccines really work anyway? And so I really like this graphic cause it shows, you know, in the pre-vaccine era, the number of vaccine preventable diseases that occurred, and then now in the um vaccination era, we, you know, we continue to see vaccine preventable diseases, we continue to see pertussis even in vaccinated individuals, but these tend to occur at a substantially reduced rate. And this was a percent reduction in diseases, incidents in the in the vaccine. Era, again, dramatic reductions. I mean, we just essentially don't see diphtheria in this country, um, you know, we still see influenza, we reduce it by having vaccinations, but we still, um, see it, uh, a reduction in invasive pneumococcal disease, measles, nearly 100% in the vaccinated population. So again, vaccines are highly effective at reducing these infectious diseases. This is another graphic I like, you know, looking at the pre-vaccine era cases of measles versus the post vaccine era. Again. Essentially shut it off once we started vaccinating uh for measles in this country. So, Uh, we know that the diseases that we are preventing are serious infectious diseases, and many of these continue to be in transmission in the US and certainly outside of the US, and vaccinations are one of the most effective strategies we have to prevent these diseases. Um, and this herd immunity provides an additional layer of protection for our young infants that can't be vaccinated or incompletely vaccinated, and for those other vulnerable populations such as the immunocompromised population. So, A question that always, I think one of the things that is at the front of parents' minds when they're thinking about vaccination is, are these vaccines safe? And so it's really important to talk to parents about what the side effects of vaccines are. So most vaccines have side effects, but they're minor. So pain, redness of Site of injection, tenderness at the site of injection, low grade fever, but serious side effects are extremely uncommon and unlikely to be permanent, so you can't have crying episodes, high fever, and febrile seizure with pertussis vaccine. You can have anaphylaxis with hepatitis B vaccine, but again, these occur at a very, very low frequency. Uh, in terms of just comparing risk, you know, for measles, your chances of dying from measles are about 2 in 1000. Um, your chances of getting encephalitis from the actual vaccine. And again, these are often difficult to approve, uh, approve anyway, but, you know, the chances of having a serious reaction from the measles vaccine are about 1 in a million. You're more likely to be struck by lightning, uh, and you're way more likely to die while walking than have a serious adverse event from the measles vaccine. So, uh, you know, how do we know this? How do we know that vaccines are safe? Um, well, we know that manufacturers, even after, you know, the, the, um, process of a vaccine being, uh, tested, researched, licensed, um, through that process, you know, tens of thousands of people receive the vaccine, and we look for safety signals in that, but, you know, 10s of thousands. People, if it's a rare event, you may not pick one up. Um, after a vaccine is, um, licensed, manufacturers continue to test lots for safety and efficacy, and FDA is involved in inspecting the manufacturers. And then the FDA, the CDC, closely monitor vaccine safety after public use, um, begins. And there are a number of different ways that we do this. There's vas. All of us can report, um, adverse events to bears, and we should, if you have a patient that has a significant event after a vaccination, it's the system of vas is really just a hypothesis generating system. So your patient, um, develops a broken arm after a vaccine or acute leukemia. You could report that. Now, it doesn't mean it caused that, but then the. Um, that system, if they get a number of reports, then can be, they can pick up those hypothesis and then test them in several other systems. And uh those systems include the vaccine safety data link, which is uh, electronic health record data from large health systems. It involves about 12.5 million people, and then they can look for those safety signals in that, um, vaccine safety data link. So they can say, does this person who received a COVID vaccine, are they more likely to Develop myocarditis. And that's how we were able to say that for adolescent men, there was a higher risk of myocarditis after the 2nd COVID vaccine. It wasn't true for the entire population, but we were able to tease that out based on the using the vaccine safety data link. Um, also, the biologic ineffectiveness safety systems can also look for these types of signals. Um, it doesn't, uh, uh, um, definitely determine causality, and it can find something that's to Statistically significant but not meaningful, but again, another mechanism for looking for adverse events after vaccination. And then if there is a severe um uh uh uh adverse event that there could be a causally related to vaccination, and there's the clinical immunization safety assessment that really reviews all the medical records, um, laboratory testing, pathology, clinical information to make a determination about a relatedness, um, for, uh, related to a vaccine. So this is the current vaccine schedule, lots of different doses of vaccine. Many vaccines are given. If you look at, uh, the vaccination schedule, when I was a kid, um, you know, we didn't get a lot of vaccines. Uh, we just, uh, you know, it's, it's really, um, you know, we, you know, had those infectious diseases instead, um, and so many people are worried that the current vaccination system overwhelms the immune system, and so it's really important to be able to address this concern. I think what I like to say to people is, have you ever seen a baby be born? Have you ever witnessed a live birth the old fashioned way? Um, if you have, you know that infants are, um, certainly primed in utero for a response to antigens, but certainly at the moment of birth, they are challenged with multiple antigens, and their immune system is capable of responding to these antigens without being overwhelmed. Um, the immune system is capable of responding to billions of antigens, and even if we give all the vaccines all at once, we really only temporarily use a 0.1% of this particular arm of the immune system. So, again, our immune system is vast and able to respond to many, many, many antigens. And if you look at the number of antigens in Vaccinations, it's actually decreased over time, even though we've given more and more vaccines. So, uh, when there was one vaccine this uh in, um, in the 1900s, there were 200 proteins or polysaccharides. In the 1960s, 5 vaccines that were given had about 3000 proteins or polysaccharides again, um, but as we have refined vaccine technology, now if. Give in 2019, 14 vaccines, only 149 to 157 different proteins are polysaccharide. So a much reduced number as we've moved away from some of those whole or live um or whole cell vaccines or other live vaccines, um, again, we see a reduction in the number of antigens and still we're able to promote that effective response. So. Um, uh, a question that won't seem to die is, is there a relatedness between vaccinations and autism? And, and, you know, you may wonder how this even got started. Um, it was, uh, based on a doctor who published a paper describing 12 children with bowel symptoms and developmental disorders, and he sort of made a link between their bowel disorders, um, a hypothesis. gut leakiness led to the release of neurotoxins and the development of autism. It turns out he was paid by a lawyer seeking to sue the vaccine manufacturer. Um, most patients in the study were contacted the lawyer, not sequentially presenting um patients as he described, and he was also seeking a patent on a monovalent measles vaccine, which is a clear conflict of interest. The data was also later determined to be fabricated, and he ultimately lost his license to practice, and the, the paper was actually withdrawn from The Lancet. But unfortunately, this is now out there, people worry about the potential link between vaccines and autism. Um, we know that developmental disorders develop during childhood, and we are giving vaccines, and many people have made that link, but multiple studies in the US and Europe have found no association between the MMR or any vaccine and the development of autism. Um, families worry about vaccines. I had a mother, uh, the other day, uh, her children are unvaccinated, and I said, you know, you know, do you have concerns? Can we talk about that? And she was concerned about heavy metals in vaccines, and there are things in vaccines that are necessary for their efficacy, um, they. Contain contain um preservatives to keep them sterile. They contain aluminum salts, about the same amount that's in formula, um, they can or breast milk, they contain some formaldehyde, um, to keep them sterile, but it's the same amount that's naturally circulating in our bloodstream. Um, polyethylene glycol, which is not the same thing not the same thing as ethylene glycol, um, there used to be erosol that's been removed from pediatric vaccines, and there was never found to be any link between a developmental disorder and the presence of thimerosol in vaccines. Uh, I had a mother, what if I breastfeed? I love breastfeeding. I breastfed my kids until they could talk. Uh, but, and we know that breastfeeding has numerous benefits to the health, but again, not enough protection against vaccine preventable diseases. It's not gonna keep you from getting measles or polio. Um, insufficient protection against the vaccine preventable diseases does appear that infants who are breastfed do have a, a, an enhanced response to vaccinations. So certainly we want to support breastfeeding, but it's not sufficient protection against vaccine preventable diseases. Um, what about delaying vaccines? A lot of people will ask, I've even had friends ask me, you know, what about just spreading things out? Um, I think it's important first to remember that young infants are at the highest risk of many of these vaccine preventable diseases. And so if we spread out their vaccine, we're really just delaying their protection. Using an alternative approach to vaccinations, it usually represents using an unstudied approach and often results in the need to visit the healthcare office more frequently, which may increase your exposure to infectious diseases, certainly will result in more painful encounters, and has no benefit to the child in terms of their protection. In fact, it's delaying their protection against these infectious diseases. So, I think, um, people in this audience could probably, uh, tell me about their experience, and you, you have much more experience talking to families about vaccination. This was a study that looked at types of, um, strategies healthcare providers use to talk to families about vaccination and encourage them, and you can see that. You know, there's a variety of different strategies that are used, and none of them are felt to be very effective. Really, the most effective thing that has been studied for vaccination is the clear recommendation from a trusted healthcare provider to vaccinate the child. That's one of the major things that can influence parents in terms of agreeing to vaccination. So, in terms of approach to parents, many families have formed ideas even before the baby is born. So if you're seeing these families in the prenatal time period, it's a good time to bring up vaccinations and your practices approach to vaccination. Um, providing written and online resources for families can help direct them to reliable sources. Um, there was a strategy on the CDC that I really, I like the, um, we're assuming you're gonna vaccinate approach. So I think, you know, it's time for your flu shot rather than you would like, would you like the flu shot? But assume people will, um, vaccinate, give your. Recommendation to vaccinate, and then, you know, if parents bring up, well, we don't really want to do that, we have concerns, um, take the time to listen and answer the questions at that point. Um, so again, we always want to be nonjudgmental and talking to families. They come from a variety of different backgrounds, health beliefs, personal experience with the healthcare system, so listening to their concerns. Empathizing with their fears, because you can fear something and it doesn't necessarily have to be real, but it can still that fear can feel very real. And then target education toward those concerns. And I like to always emphasize to families that I'm seeing. I'm often talking about vaccines in the pre-transplant era that, like, my, my top concern is to keep your, your child healthy. That's your top concern. Let's work together on this. Um, obviously sometimes parents will be hesitant. We wanna keep that, um, dialogue going, especially when we think it'll be fruitful. I think there are some people that want to convince you not to vaccinate. That's a hard, a group of people to move, but, um, when you feel like you have those families. That are on the fence and willing to listen, um, then continue that conversation at every visit to talk about vaccinations, um, acknowledge the research they've done. Obviously, we always want to be prepared with the science on vaccination. So, um, I also like to be frank with people, you know, no vaccine is 100% safe. There are side effects, but most of those are mild. There are side effects if you give your child Tylenol that are possible. So we accept that, we want to understand what those are, and then we wanna emphasize the um dramatic benefit from vaccination. Um, obviously we're always gonna respect parental authority for their child. Um, we want to emphasize ways that vaccination supports their values of keeping their child healthy, and then, you know, Document what is discussed and also provide follow up to the family, you know, either via phone call, if they're still thinking about things via email, via chat messages, and then plan to discuss it in further visits. So, um, as we are just all too aware currently, vaccine preventable diseases continue to occur, despite the fact. That we have safe and effective vaccines. Um, when we have outbreaks, that is, those are far more likely to occur in unvaccinated individuals. We really rely on having a high rate of vaccination in our community to prevent outbreaks. But unfortunately, there's a lot of false information out there, a lot of sources out there that people can turn to to get information about vaccines, um, and And um unfortunately that results in a decline in vaccination uptake, um, but we will see resurgence of vaccine preventable diseases if our community rate of vaccination continues to fall. So I think that's my last slide. Uh, if Madison wants to bring up the um QR code, I'm also happy to answer any questions.
