In 2019, the Centers for Disease Control and Prevention (CDC) reported 1282 individual cases of measles in 31 states.1 This was the largest number of cases reported in a single year in the US since 1992; the majority of cases were among people who were not vaccinated against measles.1
Conversations around vaccinations have become an increasingly common topic between healthcare providers and patients. Once a routine procedure for most providers, the discussion of vaccinations has become a problematic and divisive issue for both parties involved. Parents who refuse vaccinations for their children may also refuse to engage in conversations with their own physicians regarding the topic. The consequences of this situation are enormous. Children who do not receive vaccinations are susceptible to disease, and they may expose others to conditions they develop.
To what extent should practitioners try to intervene and communicate with parents who refuse vaccines? How should the issue be approached in the outpatient setting to maximize efficiency of care?
It is necessary to approach the issue on a deeper level to answer these questions and to fully understand the numerous viewpoints regarding vaccinations. It is useful to analyze the history of vaccinations and the widespread utilization of this tool to prevent disease, the perspectives of the patient, and recent media coverage regarding disease outbreaks. By doing so, healthcare providers will have a better understanding of an approach to the issue of vaccinations that best caters to the patient’s concerns and needs.
Certain parallels can be drawn between today’s arguments against vaccinations and those manifested when vaccines were invented. The most notable account of early vaccination is the Jenner experiment in 1796. In this case, James Phipps was injected with fluid taken from a cowpox blister on another individual.2 Merry of Bath, an outspoken critic after Jenner’s experience, noted that vaccination was “comparable with incest, introducing into the human body a disease of bestial origin similar to syphilis.”2
At first, opponents simply objected to the concept of injecting foreign material into the human body. As the use of vaccinations became more widespread, criticism grew. The Vaccination Act of 1853 mandated the use of vaccinations in England.2 For the first time, the conversation expanded from “an affair of experts contending on points of medical practice” to an issue that affected the entire nation.2 The issue was no longer simply about methodology; it became about personal rights. These rights have become the central point in vaccination conversations between physicians and their patients.
It is useful for healthcare providers to familiarize themselves with recent statistics and controversies regarding vaccinations, as concerned patients often bring up these events. An article in the New England Journal of Medicine notes that “coverage among children entering kindergarten exceeds 90% for most recommended vaccines. A closer look, however, reveals substantial local variation.”3
It is this inconsistency and local variation that puts children at risk. Vaccination rates need to be standardized across the board to reduce the outbreak of disease. Low-risk areas fundamentally become high-risk areas given the principle of communicable disease. An area that has a high vaccination rate likely still has some unvaccinated individuals. These individuals are susceptible to exposure, more so from areas with lower vaccination rates.
Two recent measles outbreaks illustrate this point. In 2014, the CDC reported a total of 125 confirmed measles cases between December 28, 2014 and February 8, 2015. “Of these, 110 patients were California residents. Thirty-nine (35%) of the California patients visited 1 or both of the 2 Disney theme parks between December 17 and 20.”4 The outbreak is thought to have been caused by international visitors from countries where measles is widespread.4 In 2014, an outbreak of 383 cases was reported in a predominantly unvaccinated Ohio community (Table). 1,5-10
Table. Recent Measles Outbreaks in the United States1,5-10
|Year||Number of Measles Cases||Complications|
|2008||January-July: 131 cases in 15 states.5||15 hospitalizations, no deaths reported.5|
|2011||January-May: 118 cases in 23 states.6||47 hospitalizations, no deaths reported.6|
|2013||January-August: 159 cases, 16 states.7||17 hospitalizations, no deaths reported.7|
|2014||668 cases in 27 states.1||Linked to large outbreak in Philippines.1|
|2015||January-May: 169 cases, 20 states.1||117 cases linked to California amusement park outbreak, viral strand found to be similar to strand causing 2014 outbreak.1|
|2016||86 cases, 19 states.8||31 cases linked to Arizona immigration detention facility outbreak.9|
|2017||120 cases10||75 cases linked to outbreak in Somali-American community in Minnesota.10|
|2019||1282 cases, 31 states||128 hospitalizations, 61 complications including pneumonia an encephalitis.|
Similar outbreaks have been reported in other developed countries. Travelers will continue to come to the United States with the disease, and the increasing number of unvaccinated individuals will remain at risk. It is crucial for healthcare providers to approach the topic of vaccinations with consistency and deliberation to prevent worsening outbreaks.