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Small Group Guide

Small Group Guide

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Published by marie_miller9478

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Published by: marie_miller9478 on Sep 20, 2011
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Small Group Discussion GuideVaccine Safety Curriculum for MedicalResidents
Case #1: Parents currently refusing all vaccines for theirinfant & considering an alternative schedule
Learning Objectives:
Clearly explain the lack of scientific evidence for a causalrelationship between vaccines and autism.
List useful facts that can allay parental fears that multiple vaccinesoverwhelm the immune system.c)Clearly explain the risks of “natural immunity”.d)Identify resources to facilitate conversations with patients and towhich you can refer patients.
Case presentation:
Both parents come into the office with their first-born daughter who is now 2months old. They are here for a well-child exam. The child was born at termand the pregnancy and delivery were uncomplicated. The parents appear tobe upper-middle class and well educated. The exam and discussion go welluntil you start to bring up the subject of immunizations. The parents statethat they have decided to delay vaccination and are considering analternative vaccine schedule in the future.
Question 1: How do you start the conservation about the parents’concerns?Answer:
It is important to validate the parents concern, not to simplydismiss them. A helpful place to start is finding out what their specificconcerns are and where the parents are getting their information.Frequently stated concerns among parents about vaccines that you mightanticipate include:
Vaccines cause autism
Vaccines cause other developmental problems
Vaccines overwhelm the immune system
We give too many vaccines too soon
Vaccine immunity in inferior and natural immunity is better
 The recommended vaccine schedule is manipulated by pharmaceuticalcompanies to sell vaccine. The government and medical communityare part of the conspiracy
What can you say to address the concern that vaccines cause autism orother developmental problems?
Page 1 of 26
Small Group Discussion GuideVaccine Safety Curriculum for MedicalResidents
Cite the multiple epidemiologic studies that have shown no linkbetween vaccines and autism.[http://www.cdc.gov/vaccinesafety/Concerns/Autism/Index.html] Youcan be very specific that MMR was not linked to autism in a largeepidemiologic in Denmark comparing children who did and did notreceive MMR. There was no difference in rates of autism. (Madsen etal, N Engl J Med 2002;347:1477) Similarly you can be very specificabout the lack of a link between thimerosal and autism. Sincethimerosal has been removed from pediatric vaccines in the Californiarates of autism have not changed. [Schechter et al, Arch GenPsychiatry 2008;65:19-24)
Cite the fact that autism is very heritable, more so than breast cancer.What can you say to address the concern that vaccine overwhelm theimmune system?
No evidence that children get more infections in the period after theyare immunized
 Your immune system responds to thousands of antigens every day
Vaccine are more pure today than 20 years ago so even though wegive more vaccines children are exposed to fewer antigens.What can you say to address the concern that we give too many vaccinestoo soon?
We give vaccines as soon as we can in order to protect infants fromdiseases when they are most vulnerable
Infants are the most susceptible to severe outcomes from infectionsbecause their organs are still developing
Infants spend many hours per day in very close contact with others-asituation that leads to transmission of things like pertussis from familymembers to infantsWhat can you say to address the concern that natural immunity is better?
Acknowledge that for some diseases that is true (e.g. varicella)
But also point out that natural immunity isn’t better for other diseases(e.g. pneumococcus) for which the vaccine contains multipleserotypes. Natural infection only protects against the one serotypeyou happen to get
Remind parents that natural immunity comes at a price-deafness,brain damage, death as a result of the disease. You are “rolling thedice” that your child will not be one of the ones who suffers severelyfrom a vaccine preventable disease
Page 2 of 26
Small Group Discussion GuideVaccine Safety Curriculum for MedicalResidents
What can you say to address the concern that the vaccine schedule is amoney-fueledconspiracy?
Remind parents that the schedule is developed and endorsed byphysicians and public health officials, not the companies
Challenge them by saying, “Do you really think all the pediatricians inthe country are conspiring to promote a schedule that we don’t thinkis safe and the best for children?”
Challenge them by saying, “Do you really think I would recommendsomething that I didn’t think was best for your child?”
Question 2: Where do parents with concerns about vaccines gettheir information?
Answer: Likely sources include web sites (mostly anti-vaccine), blogs,television, popular magazines, playground discussions, relatives
Exercise: Type “Vaccines” into Google and review the first 20 sitesquickly. How many could be classified as “anti-vaccine” sites. Read and discuss some of the theories put forth on these sites.
How can you point out in a respectful way that the information parents arereading is not scientifically based and is incorrect?
Point out some of the inconsistencies you find on these sites
Ask them why they are taking medical advice from an celebrity,friend, relative, magazine instead of from their child’s doctor
Emphasize the lack of scientific studies and reiterate the basic tenetof science-an observation needs to be repeated by independentgroups before we can really have confidence that it is correct. Noneof the claims about serious problems from vaccines have beenreproduced.What are the characteristics of a web site, specific article, or author thatgives it/their credibility?
 The source of the information is reliable/stable (e.g. AmericanAcademy of Pediatrics, World Health Organization, National Library of Medicine, NIH)
 The individuals/groups posting the information are identified andprovide contact information?
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Chris Hartman added this note
I love how in the case study of the four year old with previous vaccine reactions, they don't even bring up what the reactions were. I guess they don't even listen to the parents when they give their account of the child's reactions or take them seriously? Why do these people even TAKE a medical history on us or our children if they aren't going to listen or just assume we are making it up?
Hillary Gardner added this note
couldn't agree more cynthia. this is a ridiculous packet of info for residents who will never be one of my child's doctors. How about reading the inserts and seeing the testing results, and seeing that tdap should NOT be given to pregnant or nursing moms, and same with the flu yet dr's are pushing them. Sorry your profits are being snagged away by the public becoming EDUCATED in vax safety.
Cynthia Parker added this note
I think you should try to think what a pediatrician should say to a parent whose child has been vaccine-damaged. My daughter was given the hep-B vaccine in the hospital the day she was born, she reacted with encephalitis, and was later diagnosed with autism. When she got a DTaP booster at eighteen months, it wiped out her only two words, and she didn't say another word until 34 months old.

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