Explore This Issue
ACEP Now: Vol 38 – No 02 – February 2019If we’re the safety net we claim to be, I think emergency physicians should confront the increasing number of parents who refuse to vaccinate their kids based on nonmedical exemptions, even in the face of states increasingly requiring vaccination.1 When I spoke about this at a past ACEP Scientific Assembly, I was surprised there was some resistance to this idea, particularly in light of the measles outbreaks in New York, California, Minnesota, and most recently in Washington state, or the nationwide increase in kindergarten nonmedical exemption rates over the past decade or so. I therefore want to revisit this contentious topic, beginning with a real case.
The Case
A mother brings her 6-month-old child to the emergency department for a high fever and listlessness. The girl has a temperature of 104.9°F and pulse of 199, but she perks up with some IV fluids. Her labs show a normal total white blood cell count and a low bicarb (13). The assessment: viral illness and dehydration. However, the emergency physician orders blood cultures and antibiotics just in case. The mom refuses to allow her child to receive antibiotics because one of the girl’s older siblings reportedly experienced some antibiotic-related side effects.
The child is admitted for observation, during which time she worsens and becomes lethargic. The pediatrician’s note indicated the child was up-to-date on immunizations. Like the emergency physician, the pediatrician wants to start antibiotics, but the mother is adamant. The pediatrician documents the refusal and obtains a signed against-medical-advice form.
A lumbar puncture is performed and shows evidence of bacterial meningitis (ie, her cerebrospinal fluid grew pneumococcus), and the mom then allows antibiotics. She later admits she had actually declined to have her child vaccinated, including with Pneumovax, because she was skeptical of vaccine safety and effectiveness.
The child sustains devastating neurological injuries. The parents sue the emergency physician and pediatrician for malpractice.
When I was an emergency medicine resident in the 1980s, I got interested in infectious disease because I’d regularly see cases of bacterial meningitis in kids. However, since the introduction of the Haemophilus influenzae type B (HiB) vaccine and Pneumovax, the risk of meningitis has decreased by more than 90 percent, and I can’t recall the last time I diagnosed meningitis in a child. These vaccines have even decreased the rate of ear infections. I highlight HiB and pneumococcus because the risk of these infections to individual unvaccinated children is greater than that of largely vaccine-eliminated infections in the general population, such as measles and polio.
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10 Responses to “How Emergency Physicians Can Advocate for Vaccination”
March 10, 2019
Corey SlovisDavid, thank you for this. Greatly appreciate the summary table along with your insights.
Corey Slovis
March 11, 2019
Dave TalanThanks for the shout out, Corey. I hope you are well and taking care of our UCLA grad faculty. Let me know when I can invite myself to come visit your program, never been to Nashville.
March 10, 2019
JeffThis a way more important topic for us to address in the ED than gun control (which we have inappropriately co-opted ACEP to lobby for). Thank you so much for the practical responses to parents unreasonable excuses.
March 10, 2019
Kerry ACEP ForrestalWas the suit successful?
March 11, 2019
Dave TalanI don’t know. I hope not. The plaintiff’s attorney contacted me and I told him that there was no case and that I thought it outrageous that the family would sue the doctors for a problem that they unfortunately imposed through first, deciding to have their child not get vaccinated, second, not being honest about the child’s vaccination history, and third, refusing antibiotics when they were advised.
March 11, 2019
ANN PayneWonderful !
March 12, 2019
Leo Alonso, D.O.DR.Talan,
Thanks for your timely and well researched article. Emotionally this group of parents causes me the most moral and ethical conflict….child abuse being straightforward illegal with criminal judicial societal repercussions…this cohort of parents are afforded a degree of “free speech/thought/religious” protection while the children and the immunocomprimised suffer the consequences of their ignorance. I try to educate them in a non-judgemental fashion but my experience has been a total shutdown…they have made up their mind. I struggle with the effective approach and your article shed some light. I believe only through legislation requiring vaccinations with minimal to no exemptions will the herd immunity numbers be preserved as we enter the digital era where so much misinformation can be circulated with no counter argument.
March 17, 2019
Erin BurnhamThanks for this nice summary David. I agree that we have a duty to encourage our patients to get vaccinated. I have been even more vocal about vaccinations since the EMTs I supervise had a case of tetanus in a child. Tetanus?!
March 28, 2019
Jack SpringerDave,
Thanks for your articulate summary.
I have found the issue of trying to educate parents to change their perspective on vaccination is like having a political or religious conversation with someone of the opposite “belief”. Mostly unshakeable. Even in the face of an argument that childhood vaccinations are likely the greatest ongoing scientific experiment in history, with an N in the billions, and that they are safer than driving the family car to the ER!
April 10, 2019
Michael Herron.I thought for sure the story was going to take a turn…… we called the department of family and children services, they contacted a judge who issued a restraining order and temporary custody to the state. Child was then given IV antibiotics to treat H.flu, then suddenly developed anaphylactic shock..and died….