"I Don't Want a New Vaccine for My Child"

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Patient Presentation
A 1-year-old female came to clinic for her health supervision visit. She was developmentally appropriate, growing well, and had no previous problems with her vaccinations. Her mother had no concerns.
The pertinent physical exam showed a happy, newly-walking female with growth percentiles in the 10-50% range. Her examination was unremarkable.
The diagnosis of a healthy one year old was made. When the physician was discussing the vaccinations the mother stated that she didn’t want the new combination vaccine with the measles-mumps-rubella and varicella.
She just wanted the measles-mumps-rubella only because the chickenpox vaccine “hasn’t been around for 50 years.”
The physician discussed the potential risks and benefits of the both vaccines and also showed the mother a card with the dates of the vaccines and when they were licensed.
The mother was very surprised to learn that most of the vaccines in the recommended schedule had not been available for more than 50 years.
After more discussion, she agreed to having her daughter receive both vaccines but as separate injections.

Discussion
Parents have many questions about their children and the recommended vaccines they receive. Some parent just want more information and some parents are fearful because of inadequate or mis-information.
Parents may believe that a vaccine that is added to the recommended schedule has not been available for a long time. This is not true as some vaccines have been used in other countries sometimes for years before they are approved for use in the U.S (i.e. varicella vaccine).
Some vaccines have been available in the U.S. for limited, at-risk populations but are now being recommended for larger populations (i.e. Hepatitis A).
Some parents believe that a vaccine is “bad” because it was used in the U.S. and currently is not approved or not manufactured. This again is not true. For example, Lyme vaccine was discontinued by the manufacturer because of inadequate sales.
Rotashield® was approved but was voluntarily withdrawn in the U.S. market because of the risk/benefit balance tilted more toward the risks (i.e. risk of intussusception potentially from the vaccine versus dehydration, hospitalization, etc. potentially from the disease).
In other countries the risk/benefit balance is different and Rotashield® continues to be used successfully in those countries.

Learning Point
Although some types of vaccination have been available for more than 200 years, vaccination in its truest sense began with Edward Jenner’s smallpox vaccination in 1798. He is often considered the father of vaccination.
For the next 150 years, a few more vaccines were developed but it has only been in the past 40-50 years there has been a dramatic increase in the number of vaccines developed.
The current recommended vaccine schedule for children only has 5 vaccines that are more than 50 years old. Those vaccines are Diphtheria, Influenza, Pertussis, Polio, and Tetanus.
The table below gives an abbreviated history of vaccine licensure.

  • Diphtheria
    • 1923 – Diphtheria toxoid vaccine first licensed
  • Diphtheria-Tetanus-Pertussis-Haemophilus influenza type b-Polio-Hepatitis B Combinations
    • 1947 – Diphtheria-Tetanus toxoids vaccine first licensed (DT) in U.S.
    • 1949 – Diphtheria-Tetanus toxoids and Pertussis (DTP) vaccine first licensed
    • 1953 – Tetanus and Diphtheria toxoids (adult formulation, dT) vaccine first licensed in U.S.
    • 1991/1992 – Diphtheria-Tetanus toxoids and accellular Pertussis (DTaP) vaccines licensed for 4th and 5th doses in series
    • 1993 – Whole cell DTP and Haemophilus influenza type b vaccine (Tetramume) licensed
    • 1996 – Diphtheria-Tetanus toxoids and acellular Pertussis and Haemophilus influenza type b vaccine (Tripedia) licensed
    • 1996 – Diphtheria-Tetanus toxoids and acellular Pertussis (DTaP) vaccines licensed for entire series
    • 2002 – Diphtheria, Tetanus, acellular Pertussis, inactivated Polio, and Hepatitis B vaccine licensed
    • 2004 – Diphtheria-Tetanus toxoids vaccine, preservative free for adult use licensed
    • 2005 – Diphtheria-Tetanus toxoids and acellular Pertussis (Tdap) vaccine for adult use licensed
  • Haemophilus influenza type b
    • 1985 – Haemophilus influenza type b polysaccharide vaccines first licensed
    • 1987 – Protein-conjungated Haemophilus influenza type b licensed
    • 1988 – Conjugated Haemophilus influenza type b vaccine licensed
  • Haemophilus influenza type b and Hepatitis B Combinations
    • 1996 – Haemophilus influenza type b and Hepatitis B vaccine first licensed
  • Hepatitis A Virus
    • 1995 – Inactivated hepatitis A vaccine licensed
  • Hepatitis B Virus
    • 1981 – Hepatitis B vaccine first licensed
    • 1986 – Recombinant Hepatitis B vaccine licensed
  • Hepatitis A and Hepatitis B Combinations
    • 2001 – Combined Hepatitis A and Hepatitis B vaccine licensed
  • Human Papilloma Virus
    • 2006 – Human Papilloma Virus vaccine licensed
  • Influenza virus
    • 1945 – Inactivated influenza vaccine first licensed in U.S.
    • 2003 – Live, attenuated, intranasal influenza vaccine licensed
  • Japanese Encephalitis Virus
    • 1992 – Inactivated Japanese Encephalitis vaccine licensed
  • Lyme Disease
    • 1998 – Lyme vaccine licensed (voluntarily withdrawn from market because of insufficient sales)
  • Measles Virus
    • 1963 – Live measles vaccine licensed
    • 1965/1967 – Another live measles vaccine licensed
  • Measles-Mumps-Rubella-Varicella Virus Combinations
    • 1971 – Measles and Rubella, and Measles-Mumps-Rubella vaccines first licensed
    • 1973 – Measles-Mumps vaccine first licensed
    • 2005 – Measles-Mumps-Rubella-Varicella vaccine first licensed
  • Meningococcus
    • 1974 – Monovalent meningococcal polysaccharide vaccine (Group C) first licensed
    • 1978 – Monovalent meningococcal polysaccharide vaccine (Group A) and Bivalent Group A and C vaccine first licensed
    • 1981 – Quadrivalent Group A, C, Y, and W-135 meningococcal vaccine first licensed
    • 2005 – Quadrivalent Group A, C, Y, and W-135 polysaccharide – Diphtheria toxoid conjugate vaccine licensed
  • Mumps Virus
    • 1967 – Live Mumps vaccine first licensed
  • Pertussis
    • 1915 – Pertussis vaccine first licensed
  • Plague
    • 1897 – Plague vaccine first used
  • Pneumococcus
    • 1977 – Pneumococcus vaccine (14-valent) first licensed
    • 1983 – Enhanced pneumococcus vaccines (23-valent) licensed (replaces 14-valent vaccine)
    • 2000 – Conjugated pneumococcus vaccine (7-valent) licensed
  • Polio Virus
    • 1955 – Inactivated Polio vaccine (IPV) first licensed in U.S.
    • 1961 – Oral Polio vaccine (strains 1 and 2) first licensed in U.S.
    • 1963 – Oral Polio vaccine (strains 1, 2, and 3, OPV) first licensed in U.S.
    • 1990 – Enhanced-potency inactivated Polio vaccine licensed
  • Smallpox Virus
    • 1100 – Violation used in Turkey, Africa, China and Europe
    • 1721 – Violation used in Great Britain
    • 1798 – Vaccine developed by Edward Jenner
  • Rabies Virus
    • 1885 – Rabies vaccine used in humans by Louis Pasteur
    • 1914 – Rabies vaccine first licensed in U.S.
    • 1997 – Rabies vaccine licensed by another manufacturer
  • Rotavirus
    • 1998 – Live, oral rotavirus vaccine licensed (voluntarily withdrawn from U.S. market in 1999 because of concern of intussusception, still used in other countries)
    • 2006 – Different Live, oral rotavirus vaccine licensed
  • Rubella Virus
    • 1969 – Rubella vaccine first licensed in U.S.
    • 1980 – RA 27/3 strain of Rubella vaccine licensed (all other strains discontinued)
  • Tetanus
    • 1927 – Tetanus toxoid first licensed
    • 1937 – Tetanus toxoid adsorbed vaccine first licensed in U.S.
  • Tuberculosis
    • 1927 – BCG (Bacille Calmette-Guerin) vaccine first used
  • Typhoid
    • 1914 – Typhoid vaccine first licensed in U.S.
    • 1952 – Heat-inactivated typhoid vaccine licensed
    • 1989 – Live, oral typhoid vaccine licensed
    • 1994 – Inactivated, injectable polysaccharide typhoid vaccine licensed
  • Varicella Virus
    • 1995 – Live, varicella vaccine licensed
    • 2006 – Herpes zoster (shingles) vaccine licensed
  • Yellow Fever
    • 1935 – Yellow fever vaccine first licensed
    • 1953 – Yellow fever vaccine first licensed in U.S.
    • 1978 – Another Yellow fever vaccine licensed

Questions for Further Discussion
1. What are the potential risks of vaccinations?
2. How common are vaccination side effects?
3. When were penicillin and sulfa drugs first developed?
4. When were x-rays first used?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Childhood Immunization and Immunization

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Immunization Action Coalition. Historic Dates and Events Related to Vaccines and Immunization. Available from the Internet at http://www.immunize.org/timeline/ (rev. 1/17/2007, cited 4/30/2007).

Colon AR, Colon PA. Nurturing Children A History of Pediatrics. Greenwood Press. Westport, CT. 1999.

World Health Organization. History of Immunization. Available from the Internet at www.childrensvaccine.org/files/WHO-Vaccine-History.pdf (cited 4/30/2007).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    June 11, 2007

    • Published