If 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.
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.