Vaccination Guest Post: Is there value in delaying?

(This is the third post in a series of guest posts by Dr. Mark McColl on vaccinations.  We don’t have to agree on this topic to still be sisters and friends.  I’m providing these posts as a source of information for those who are still doing research, not those who have their minds made up.  Please read my vaccine history and the introduction of Dr. McColl before proceeding with Posts 1 and 2 and then reading this one.)

It seems like part of our nature to try and make sense of drastically different viewpoints by compromising to a middle ground.  Somehow we believe that moderation is a better option than either extreme.  Right wing and left wing politicians need to come together somewhere in the middle to get things done.  Low fat versus low sugar diets are at odds with each other.  Isn’t it best just to eat ‘everything in moderation’?  This flawed logic argument is called the golden mean fallacy.  Either extreme makes us feel like we are drawing a line in the sand and choosing sides when really we just want everyone to get along.

In the vaccine debate there are those who say we should fully vaccinate our children on schedule and those opposed who believe that all vaccines are toxins to the body and should be avoided.  Many have taken the golden mean and proposed a slower schedule in an attempt to compromise.  But should we compromise?  Do we think compromise is good for other aspects of our children’s health and safety?

We believe our children shouldn’t have any arsenic in their school lunches.  We believe the bus driver shouldn’t have any alcohol in their system on the way to school.  We think the first ride in the car home from the birthing center needs to be in a five point harness of a car seat.  So in the debate on schedules we should look at it from what is a good idea for our children and not trying to find a compromise between two stated opposing viewpoints.

I believe that the soonest we can protect our children from a preventable fatality or injury we should.  That really is the basic idea behind the national and international guidelines for vaccinations.  The general thinking is why wait to do anything that can protect our children when it can safely be done now.  Some vaccines prevent against diseases which typically only affect certain age groups.  For instance Streptococcus pneumoniae and Haemophilus influenzae type b which both cause serious brain and blood stream infections most commonly occur in children under the age of five.  About 90% of these infections occur in children less than 2 years of age.  So it is advisable to receive these vaccinations as young as it is medically appropriate.

Other vaccinations such as Hepatitis B have a different risk profile.  Historically, the greatest risk of an infant contracting Hepatitis B was at delivery.  For many years, prenatal care was sparse and routine testing for Hepatitis B was not done.  In some places women only present to their local health care provider at the time of delivery.  In these cases, if the mother does have Hepatitis B there are a few things that can be done to help cure the child.  One of which is to give the Hepatitis B vaccine.  With that initiative over the years the safety of vaccinating newborns was well established and that has become the standard of care in many communities.  Altering that schedule for children born to women known not to have Hepatitis B and not exposed to Hepatitis B in their household is often proposed.  The question revolves around deciding at what age do we believe the child begins to have risk and do we believe we can fully know when and how the risk will occur.  If we decide to wait one month, two months, or two years to vaccinate against Hepatitis B how much are we increasing the risk of that child acquiring the disease?

That question is hard to answer because we can’t predict the future.  In my own practice, 100% of the newborns I care for in the hospital nursery have been born to a mother who knows her Hepatitis B status.  Infants born to mothers who do not have Hepatitis B and do not have an expected exposure in the first two months of life are offered a delayed vaccination.  Hepatitis B comes in a combination shot that I stock in my office.  I can use this combo shot, administer Hepatitis B with the other scheduled vaccines at two months of age, and reduce needle sticks the child will receive in order to be fully vaccinated.  I believe the very low risk of acquiring Hepatitis B if a child has no perceived exposures is worth reducing the number of times they need to be poked with a needle.  That’s a very fine line to walk.  I wouldn’t feel comfortable waiting two years to vaccinate for Hepatitis B.  Additionally, if the parents were planning foreign travel or had a household member with active Hepatitis B I would recommend the vaccination at birth.  So you can see that even in an infection that is relatively hard to transmit it is difficult to justify a delayed schedule because there are still so many unknowns.

As this thinking of timing of risks and possibility of delay works its way through the other vaccines, I’ve had several families approach me with various ideas for a delayed schedule.  Although there is no documented benefit of a delayed schedule and no documented risk of vaccinating along the national guidelines, families still sometimes propose this approach.  The most commonly proposed alternate schedule comes from a popular book on vaccinations published a few years ago.  I have serious concerns as to the motivation behind this different schedule.  It increases the number of office visits needed for check ups and vaccinations substantially.  In the author’s own private practice he does not accept medical insurance and requires fee for service payment directly from the patient’s family.  So families attempting to follow his recommendations for a delayed schedule have approximately 2-3 times the number of visits to his office than the standard check up schedule.  The cost of the vaccines comes out of pocket as well.  I can’t help but wonder if there isn’t a financial motivation behind all this given there is no published scientific evidence for its benefit.

From a practical standpoint I know delayed schedules don’t work in my office.  Procrastination rarely does.  Early in my practice I had several very winsome and gracious mothers convince me to try a delayed vaccination schedule with their children.  We worked the program diligently.  I even printed out the agreed upon delayed schedule and kept it handy for all their visits.  It became clear early on that these children were always behind on their vaccinations even by the delayed schedule standard.  In the end when kindergarten was just around the corner we had a lot of catching up to do.

I kept feeling as though we were not protecting these children as well as we could.  I would catch myself holding my breath hoping nothing was going to happen to them as we waited another month to do the next vaccination.  After those experiences I’ve declined to enter into further delayed schedules.  I know I can’t adequately take care of these children that way.