Childhood Immunization

Introduction

Nothing concerns a health care provider more than walking into a patient’s room to take a history and realizing that the child or adult you are attempting to treat never received vaccinations. Unfortunately, this situation and the number of “anti-vaxxers” in the United States are becoming a prevailing trend.

This is regrettably proven by the increase in certain preventable yet deadly diseases like measles. In fact, “The largest measles outbreak in the United States in more than 20 years occurred in 2014” (Smith, 2015). These numbers correlate directly with recent events of parents deferring the MMR vaccine and labeling it as taboo (Smith, 2015).

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The life of a child is precious, and parents become overwhelmed when trying to pick the best course of action to keep that child healthy. For this purpose, it is incredibly important to determine those affected by this public health issue, how it originated and its prevalence, as well as ways to improve upon it as healthcare professionals.

The Community Effect of Not Vaccinating (Scope of the Problem)

An estimated 3.4 million kids under the age of five die from diseases of infectious origin each year (Clift & Rizzolo, 2014). Imagine this number without childhood immunizations. The World Health Organization has actually made it known, that “immunizations save two to three million people each year from vaccine-preventable disease such as measles, pertussis, and influenza” (Clift & Rizzolo, 2014). It is unfortunate that despite these facts, parents are still hesitant to grant their children immunity.

Not only does this issue affect children directly, but it also has an impact on the community. “Herd immunity” can be defined as a “reduced risk of exposure to pathogens”, which is achieved when a large portion of a population is immune to specific diseases (Ventola, 2016). This protects people who cannot receive certain vaccinations, like immunocompromised individuals, from actually contracting these infections. However, for herd immunity to be efficient, “an immunization rate of 95% is required” (Clift & Rizzolo, 2014). With the recent decrease in the use of vaccines, the lives of other patients are at stake. A systemic review published in 2010, unsurprisingly determined that herd immunity was not a factor that parents considered when deciding whether or not to vaccinate their child, despite them being aware of the concept and the benefits it contributes to society (Schwartz & Orenstein, 2001).

Overall, vaccine hesitancy is directly impacting the lives of children, as well as indirectly affecting the lives of those who actually would be harmed if they received vaccines. As health professionals, it is our duty to be fully aware of this growing public health concern and to know how to address and recognize a parent who is struggling to reach a decision. In addition to this, it is imperative that the original etiology of this movement, along with other reasons that undermine the value of vaccines are well understood.

Etiology/Prevalence

Some may find it as a shock that the crusade against childhood immunizations is not that modern of an idea. The outbreak of apprehension actually started in the 1700’s, when the smallpox vaccine was first established (Clift & Rizzolo, 2014). Concerns regarding the vaccine centered around “safety, religious objections, and skepticism of science”, which are very similar to the challenges immunizations are trying to overcome today (Clift & Rizzolo, 2014). Regardless, the smallpox vaccine did show its worth after completely eradicating the disease from the United States.

It is also a misconception that this controversy over vaccines started with the claim that the MMR immunization was directly linked to causing Autism Spectrum Disorder (ASD). However, the concept first gained its appeal around 1982, when a film titled “DTP: Vaccine Roulette”, claimed that the DTaP vaccine resulted in the development of encephalitis. This side effect was only associated with the “”whole-cell pertussis vaccine””, which has been out of commission since 1991 when the “”acellular pertussis vaccine (DTaP)”” was put on the market. With this adjustment, the immunization “shows no evidence of encephalopathy postvaccine and a much lower incidence of febrile seizures than the whole-cell version”. However, it is worth noting that the incidence of encephalopathy with the “whole-cell vaccine” was “1 to 10 cases per 1 million” people receiving the vaccination (Clift & Rizzolo, 2014).

Although these shortcomings are minor, it still gave the media the fuel to continue to build on the downfalls of childhood immunizations. In 1998, Andrew Wakefield published an infamous paper that still continues to change the way parents conceptualize vaccines, despite the fact that its claims and research did not reach the standards of evidence-based medicine. Wakefield’s original hypothesis linking the MMR vaccine to ASD, stemmed from the idea of the immunization causing “”ileocecal lymphoid hyperplasia”, which lead to the buildup and release of peptides from the intestines. These peptides were theorized to cause permanent brain damage and an increased risk of developing ASD (Clift & Rizzolo, 2014).

However, there were multiple flaws to this study that parents need to be aware of. For example, there were only a total of 12 children participating, it lacked a control group, and the researchers who participated in the analysis were not blinded when evaluating endoscopic histological results. In addition to this, Wakefield’s hypothesized peptides were never discovered throughout the study. He himself claimed that he could not prove a correlation between the two and that more research needed to be conducted. For this reason, a number of journals have further explored the hypothesis, but none of them have found in favor of the theory. In fact, a Canadian study that strictly “looked at the pervasive developmental disorder rates with respect to the MMR vaccine”, revealed that there was an increase in diagnoses of ASD, with the recent reluctance of parents to want to give the immunization to their kids (Clift & Rizzolo, 2014).

In addition to these etiologies, Thimerosal, a mercury-based preservative found in non-live immunizations, has also been a concern of parents. The media has linked this ingredient to the buildup of mercury in children, correlating it to the development of ASD and other adverse neurological side effects. In response to these assumptions, the ingredient was removed from the majority of vaccines, and the practice of administering multiple dosages of immunizations at a time with the ingredient was discouraged. However, these improvements were most likely unjustified, since thimerosal is broken down into ethyl mercury in the blood. This is known as a non-toxic metabolite that has a much swifter half-life and metabolism than methylmercury, the true toxic form of mercury (Clift & Rizzolo, 2014).

These claims illustrate the origin of this outstanding public health issue and are a common answer to the question, “why are you choosing not to vaccinate?” However, parents also defer immunizations for “religious, philosophical, and socioeconomic reasons” (Ventola, 2016). For instance, some guardians believe “that natural immunity is better for their children than is immunity acquired through vaccinations” (McKee & Bohannon, 2016). “Others express the belief that if their child contracts a preventable disease, it will be beneficial for the child in the long term, as it will help make the child’s immune system stronger as he grows into adulthood” (McKee & Bohannon, 2016). Finally, some feel that the entire concept of receiving multiple immunizations at one time could in no way be beneficial and that it will ultimately lead to an overload of the child’s immune system (McKee & Bohannon, 2016).

It is evident that there are an array of explanations for choosing in favor of natural immunity, but what also needs to be made known is how communal it actually is becoming. On average, “1 in 20 to 1 in 50” children walking into a pediatrician’s office have not obtained their childhood immunizations (Block, 2012). In addition to these facts, the recent childhood prevalence of these avoidable diseases directly reflects the growing number of parents deferring immunizations. For instance, in 2011, 24 states reported a total of 118 cases of measles, 89% of which did not receive any doses of the MMR vaccine (Insel, 20212).

Intervention/Prevention

Like any kind of medical intervention, it is imperative to consider the risks and benefits of initiating vaccinations that are specifically tailored to the individual child. Fortunately, the benefits usually outweigh the risks, which is why a healthcare professional should be well-versed in presenting the facts to a parent who is deferring the standard of care. The “AMA Journal of Ethics”, determined that the majority of parents prefer to use healthcare professionals as their primary resource for vaccine information over any other source, proving that our role in this situation is crucial (Insel, 20212).

As with any form of patient counseling and education, a provider should start by presenting the facts as well as inquiring about any specific concerns a parent may have. A healthcare worker should be able to respectfully refute misconceptions that parents have discovered, despite their origin. In addition to this, a fundamental part of this process is presenting guardians with concise yet accurate information regarding the topic so that deferral of immunizations is prevented from the get-go. It has been determined that the earlier this process starts the better. Some would even say that “prenatal open houses or during postpartum visits on the maternity ward” could be optimal times to direct parents to the appropriate sources (Smith, 2015).

In contrast to this preventative approach, it may be beneficial to stop harping on vaccine safety when it comes to counseling parents who already made up their mind. Instead, discuss cases or present pictures of children affected by these diseases. When a clinician refutes a parent by offering facts on vaccine safety, it can come off as argumentative. However, if one is to stay on the same train of thought as the parent, which is most likely something harming their child, they are more likely to be swayed. “Defining the health risks, as well as the potential for large medical bills, often provides parents with a clearer picture with which to better assess their decision” (Ventola, 2016). In addition to this method, providers have been leaning towards a “presumptive approach”, which ultimately follows the recommendation that every parent should be addressed as if they have already decided to vaccinate (Smith, 2015). This theory has been tested and actually proved to be more effective than “participatory approaches that allowed for more parental decision-making” (Smith, 2015).

Along with these strategies, there have also been government based as well as community-based interventions put in place to boost immunization rates. One particularly effective policy is based upon using “public reminder and recall strategies”, like phone calls and emails, to remind parents that their child needs to be brought in for their next dose, in order to boost adherence rates (Ventola, 2016). In addition to this, “alternative public and private venues for vaccinations””, like daycares and walk-in clinics have been working to make immunizations more accessible to the public In some areas, local venues offer immunizations free to uninsured parents, and rewards, such as gift cards, are rewarded after the immunization is performed to boost motivation to come back (Ventola, 2016). Finally, the CDC formulated the Advisory Committee on Immunization Practices (ACIP) in 1994, which is responsible for continuously reviewing literature in regard to vaccine safety and efficacy, researching the incidence and mortality of these preventable diseases, and working to determine immunization accessibility and acceptance. This growing government program was established to ease the minds of parents by offering persistent monitoring of vaccines and their reported side effects (Schwartz & Orenstein, 2001).

Despite the fact that this topic is relatively new and not yet thoroughly researched, it has become a common finding in a variety of studies “that a trusting relationship is the single most important element in vaccine risk communication” (Smith, 2015). With that being said, regardless of what approach a health care provider chooses to address their patients with, it is imperative that they make it known that the advice they are offering is in the best interest of that child.

Summary

It is evident that childhood immunizations play a vital role in protecting children from deadly diseases, however, they also work to build the backbone of our community’s immune system. For these reasons, it is imperative that researchers continue to study and disprove misconceptions in regard to their side effects, as well as improve the vaccination schedule itself so that it is more adherable and accessible. Healthcare providers also need to play their role by being well versed in immunization safety and having strategies in their back pocket to prevent vaccine hesitancy and deferral.

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