Case ReportAbstract
In Romania, as in the rest of the world, there is an increase in the number of measles cases, a consequence of the vaccine hesitation. In this paper, we propose to discuss a case from our medical practice: the parents’ refusal to vaccinate their children against MMR (rubella-mumps-measles) on the one hand and, on the other hand, their teenage son desire to be vaccinated, so that he would be protected of infections that can affect his health.
Keywords: MMR Vaccine; Ethics; Family Medicine
Abbreviations:MMR: Measles-mumps-rubella; WHO: World Health Organization; CDC: Centers for Disease Control; APA: American Pediatric Association
Introduction
Vaccination is one the most cost-effective methods to prevent
infectious diseases, including measles. Vaccine hesitancy - reluctance
or refusal to be vaccinated or to have one’s children vaccinated
against infectious diseases, despite the availability of vaccines -
may reverse progress in addressing vaccine-preventable diseases.
In 2019, the WHO announced that the vaccine hesitancy is one of
the ten problems of global health [1]. In general the main worrying
themes related to vaccines are autism, neurodevelopmental
disorders, Guillain-Barre syndrome and the possible association of
several vaccines with some chronic diseases that at least potentially
have an autoimmune etiology [2].
A 1998 study published in the Lancet, a renowned medical
journal, put a universal tool in front of anti-vaccinists [2]. The
article stated that the measles-mumps-rubella (MMR) vaccine
has caused childhood developmental disorders, including autism
spectrum disorders. Nearly two decades of further research
failed to prove these claims, and 10 of the 13 original authors in
the paper later withdrew their support for the study’s findings
[3]. In 2010, the Lancet withdrew the original article when it was
revealed that the data in the study had been modified to reach the
desired conclusions [4]. However, in the years between the original
publication of the Lancet and its withdrawal, this case is credited
with lowering MMR vaccination rates from a maximum of 92% to a
minimum of almost 60% in some areas of the United Kingdom. As
a result, the expansion of the population of susceptible individuals
has led to increased rates of measles and mumps infection and is
credited with thousands of prolonged hospitalizations and several
deaths of infected children [5].
In Romania, as in the rest of the world, there is an increase
in the number of measles cases, a consequence of the parents’
choice to refuse to vaccinate their own children. The public health
authorities of Romania officially declared a measles epidemic in
September 2016 and started an information campaign to encourage
parents to have their children vaccinated. In our country, the main reason for this increase is the MMR vaccine hesitancy, given the
lack of confidence or satisfaction and less the limitation of access to
vaccination [6]. The autism link to MMR started, as we mentioned,
with an article that years later was proved to be false, but the
misconception continues until our days and this information is
perpetuated as a fact and lead to a significant number of preventable
death [7].
One of the compounds that has attracted criticism is thiomersal,
an antifungal agent used in small amounts to prevent contamination
of preparations in some multi-dose vaccines (the same bottle is
opened and used for several patients). Although its efficacy is
undeniable due to the fact that this compound contains mercury
(ethyl-mercury), in 1999 the Centers for Disease Control (CDC) and
the American Pediatric Association (APA) recommended vaccine
manufacturers, as a precaution, to eliminate thiomersal. The action
raised concerns that thiomersal could have been responsible for
autism. The idea is now considered unjustified, as incidence rates
for autism have steadily increased [8], even after thiomersal has
been removed from childhood vaccines [9]. There is currently no
scientifically accepted evidence that thiomersal exposure is a factor
that causes autism or other neurological disorders [10]. Refering
to the vaccine overload, vaccines have a very low immunological
load compared to pathogens naturally encountered by a child in a
typical year; common childhood conditions, which cause fever and
upper respiratory tract infections, are a much bigger challenge for
the immune system than vaccines and studies have shown that
vaccination, even at multiple concomitant doses, does not weaken
the immune system [11].
Case Discussion
14-year-old boy showed up at the family doctor’s office
accompanied by his mother to be vaccinated according to the
national vaccination schedule. It is the first consultation after
about a year and the doctor is pleasantly surprised by the physical
and neuropsychic development of the adolescent, although from
his ironic tone, one can observe an age-specific conflict with his
mother. A short conversation with the young man brings to the fore
the interest regarding his health condition and the doctor reminds
the mother that a dose of MMR vaccine is overdue. The mother of
this young man is a highly educated person with a respected social
status. However, she has doubts about the safety of administering
this vaccine to her son, being under the influence of articles
published years ago (which later proved to be inconclusive), but
also of some public figures without medical training affiliated or
not religiously.
Driven, probably, by age-specific inner conflict but especially
because he is an intelligent and informed teenager, the boy confronts
his mother during the discussion and signals to her the lack of
accuracy of the facts on which her decision to refuse the vaccine is
based. Furthermore, being a participant in school competitions in the field of natural sciences, he showed that he is concerned about
the consequences of the infection on the body if he were infected
with the measles virus. Therefore, he decides to inform the doctor
that he wants to be vaccinated even if the mother opposes.
What should the doctor do?
In order to manage the situation in the most delicate way, the vaccine was administered according to the age of 14 and to the mother it was explained that some of the information she has is outdated and that all current scientific evidence contradicts excessively propagated anti-vaccine myths. The mother agreed to reconsider the decision, going to talk to the father and the teenager and a new meeting was scheduled 1 month apart.
Discussion
Some questions remain related to this case. If the doctor fails to
eliminate the parents’ vaccine hesitancy, should the authorities be
notified, or should they respect the parents’ decision? If the parents
won’t agree to the administration of MMR vaccine, should the
adolescent refer to the child protection authorities? Often there are
families in which the child is much better informed than the parents
who are under the influence of religious or cultural barriers. In
our experience [12], educated adolescents are much more careful
to comply with SARS-CoV2 infection prevention measures. How
will we proceed when the Covid-19 vaccine is available, and the
parents refuse the vaccination? Should there be uniform penalties
in all states for refusing vaccination? In the context of the lack of
vaccination, is it possible that the adolescent and then the young
adult will not be allowed access to certain states of the world? Isn’t
this restriction on the right to free movement a consequence of the
decisions taken by parents?
Laws generally assume that parents make decisions based on the
best interests of their children. Indeed, parents have the freedom to
raise their children in accordance with family beliefs and personal
values [13,14]. With regard to health care, laws generally require
government agencies and courts to revoke parental authority only
when parental decisions amount to child abuse or neglect, and the
neglect provisions usually only involve substantial life-threatening
situations [15]. The extent to which vaccination hesitation can
become life-threatening is a lesson we should already know.
Conflict of Interests
We have no conflicts of interest to disclose.
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