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The Twilight Zone

The Twilight Zone

Just when you think you have heard it all, seen it all and done it all, people show up in the field of medicine and give you another experience from the Twilight Zone.

Several weeks back, a young adolescent girl returned to our office for her twice yearly visit. She has had a long history of asthma related illnesses. On that day, she was wheeze free and in good spirits. She has the stature of a young woman so it would be easy to mistake her for a much older person. Her medical biography only spans thirteen years or so, but her breathing problems have gotten her admitted to the intensive care unit at Le Bonheur at least two times of which I am aware. She has had countless trips to the emergency department as a result of exacerbations of her asthma. Her mother who is a PhD researcher employed at our local medical school related that vaccines cause her daughter's asthma to flair, so she tries to keep her daughter from getting any vaccine which is not absolutely necessary. The child is deathly afraid of being vaccinated because she had one of those ICU admissions occurred after a routine vaccine administration.

The private Christian school that the child attends has a standard policy making students who attend maintain a CDC vaccination schedule. I will not expound on the vaccine controversy that is brewing amongst government and public health administrators who are in favor of thirty or more vaccinations before school verses parents who wish to take a much more moderate approach because that topic could be the subject of a long diatribe. The mother of the child asked me to write a letter to the school, asking for waiver of her upcoming Tdap vaccination because she was concerned that her daughter's asthma would flair as a result. It seemed like a logical request to me since she her daughter had several severe asthma reactions in the past when she was vaccinated. So I agreed and wrote the letter.

About two weeks later, the school nurse who has been empowered to enforce the school policy on vaccinations called my office demanding to speak to me. I was surprised but happy to engage in a conversation with her about my patient. It turned out that we did not have a conversation. The school nurse was adamant that the child receive the Tdap vaccination as soon as possible and that I needed to provide her a date on which the vaccination would be given to make sure she caught up to the school's policies on vaccines. She would not listen to anything I had to say about the subject, after all she was the school nurse in charge of compliance. All I could tell her was that I would reconsider an administration of the Tdap vaccination when the child was not in school, so that if the child had a severe reaction like she did with other vaccinations, she would not miss school and get behind. The nurse was not happy that a date of vaccination was not set in stone.

About one week later, a local allergy specialist physician called my office and wanted to speak to me about my letter to the school. After playing phone tag for a week, we finally spoke. I let him know my concerns about the Tdap vaccination for my patient. He was not open to any idea that a Tdap vaccination could cause an allergic asthma like reaction in a young adolescent child who has been afflicted with asthma. He remarked that I needed to report the reactions to the CDC. He said if young adults have reactions to the shot, he stated he would concur with me and not vaccinate her. However, he did not believe it was possible. He stated that the school was concerned for the safety of all the children in the school and the risk of an unvaccinated child was unacceptable since other children could possibly be exposed to one of the three diseases Diphtheria, Tetanus or Pertussis if my patient would come to school with one of those afflictions. I listened carefully. I was surprised at his comment since he clearly did not understand the dynamic at work in this situation. I replied that my patient was ill, she would not put any vaccinated child at risk if the vaccines worked; she would be at risk from the other children and her mother was willing to take that chance since the probability of her contracting any of the three illness in our county is infinitely small. He thought for a moment and concurred. I thought we understood each other, and he left the conversation agreeing with my position.

One week later I spoke to the mother of the child and she related the Headmaster of the school had called her one day ago. She related that he told her that if her child was not vaccinated by Fall Break, she would be expelled from the school. Her understanding was that the Allergist researched the potential risk for an asthma like reaction to the vaccine and related it would never happen. The headmaster offered to arrange her child to be seen by the Allergist so that the mother could get a better idea of the risk/benefit of the vaccine. The mother made no decision at that time.

The Allergist did not call me back to relate that he had changed his position about the vaccination; instead of holding it, he wanted her to receive it. Not only is his decision making flawed in this case, he is unprofessional to boot. Perhaps he is conflict adverse of which most people would label him a coward. The specialist did not have courage to re-engage in a conversation with the child's physician (me) and discuss the matter at length. He simply made a call to the Headmaster and supported the administrator's decision for the vaccination.

My quandary is simple. If she gets the vaccination with my full knowledge that she would most likely have an asthma attack, would I be held liable if she had to be hospitalized or God forbid died? Would the Allergist and Headmaster come to my defense and help diffuse the pain and agony of a mother losing a child? Who could explain to the mother that her child's reaction was necessary for a vaccine that might protect her from diseases that were common one hundred years ago and all three are almost unheard of in a clean, well kept environment?

In the case of Pertussis or Whopping Cough, 32,971 cases were reported to the CDC in 2014 and it usually affects children under the age of one year old or adults over sixty-five. My patient is thirteen years-old.

According to the CDC, between 2004 and 2008, no cases of diphtheria were recorded in the U.S. At the writing of this blog, the CDC has not reported a case of Diphtheria in a US citizen in years. In 2011, 4,887 cases of diphtheria were reported worldwide to the World Health Organization (WHO). We have about six billion people on our planet.

During the period 2001-2008, a total of 233 cases and 26 deaths from tetanus were reported in the United States. Seventy one (30%) were in persons aged 65 years or older, 139 (60%) were in persons aged 20-64 years, and 23 (10%) were in persons younger than 20 years, including one case of neonatal tetanus. The risk of dying from tetanus was five times greater in patients >65 years. During each of these years, coverage among infants and children with at least three doses of DTP/DTaP/diphtheria and tetanus toxoids (DT) was 94% or higher. My patient has had at least four doses of DTaP and her reactions to the shots are getting increasingly worse.

There are 315,000,000 or more people living in the United States making Tetanus and Diphtheria almost unheard of and Pertussis a rare disease. One can see that the vaccination in question has very little benefit for a young girl living in Cordova, Tennessee. In Memphis, on average, four to five cases of Pertussis are reported each year. Shelby County health department has not published an incidence of tetanus or Diphtheria that I am aware of since moving here in 1991. My patient has a much greater risk of being injured or killed in an automobile accident going to and from school than becoming ill from Tetanus, Diphtheria or Pertussis.

So what is all the harangue about anyway? This statement has been lifted directly from the CDC website on the incidence of side effects from the DTaP/DTP/Tdap vaccine, Getting diphtheria, tetanus or Pertussis disease is much riskier than getting DTaP vaccine. However, a vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of DTaP vaccine causing serious harm, or death, is extremely small. But death does occur from vaccines in about one in a million people. Why not just hold the inoculation in light of the fact that her mother reports that her daughter has serious allergic reactions to vaccines and the public health data in Shelby County is absolutely clear that while her daughter is attending school in our county, she will not contract Tetanus, Pertussis or Diphtheria?
I foresee this battle of wills is not over. The mother is assessing her options. More important, other parents are facing the same situation in this Christian school and other schools as the climate of dissension is warming up between the parent's right to choose what's best for their child and an institutions will to force its adopted policies on their children regardless of the consequences to the child's health.
See, we have entered the Twilight Zone.
Doc

Posted by Amanda Sanders at 11:04 AM
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