By Dr. Sherri Tenpenny, DO, AOBNMM, ABIHM
Veterinarians and pediatricians have a lot in common. Both are highly qualified professionals with similar credentials, including years of education. Both often struggle to determine what is wrong with their patients since pets, like little people, cannot directly communicate what hurts. Their jobs are not easy, but the premise of their work is simple: Support the health of those in their care and abide by the oath, “First, do no harm.”
Wellness checkups for babies and pets are often synchronized with routine vaccination schedules. For human patients, this is where the discussion with their doctor can turn dark. Parents have heard stories of families being discharged from a medical practice for questioning vaccines and are wary to bring up their concerns. Their fears are not unfounded. According to a 2015 study published in PEDIATRICS concluded,
“Of the 815 pediatricians surveyed, 534 responded. Almost all respondents had had encounters with parents who refused infant vaccines. One-fifth of the responding pediatricians reported dismissing families who refuse, but there is substantial variation in this practice. Given the frequency of dismissal, the impact of this practice on vaccine refusers and on pediatric practices should be studied further.”
Pet owners, on the other hand, pay attention to an owner’s vaccination concerns. In many cases, refusing a vaccination has the full support of their vet.
Puppies and kittens
When it comes to dogs, veterinarians can tailor the vaccination schedule to the pet. The 2017 Canine Vaccine Guidelines and Recommendations recognize vaccination as a medical procedure that needs to be individualized based on the animal’s geographic exposure and lifestyle. The American Animal Hospital Association, a vet’s professional organization, encourages doctors to spread out vaccination intervals for the safety of the pet.
Veterinarians limit the number of vaccines given to puppies on a single visit. In 2005, electronic records from January 1, 2002, through December 31, 2003, were searched for possible vaccine adverse events (VAAE), such as nonspecific vaccine reaction, allergic reaction, urticaria, or anaphylaxis. The search looked specifically for reactions within 3 days of vaccine administration. Published in the Journal of the American Veterinary Association, the research revealed the following:
Our search found 4,678 adverse events (38.2/10,000 dogs vaccinated). The VAAE rate decreased significantly as body weight increased. Risk was 27% to 38% greater for neutered versus sexually intact dogs and 35% to 64% greater for dogs approximately 1 to 3 years old versus 2 to 9 months old. The risk of a VAAE significantly increased as the number of vaccine doses administered per office visit increased; each additional vaccine significantly increased risk of an adverse event by 27% in dogs less than 10 kg (22 lb) and 12% in dogs greater than 10 kg.
Conclusions and Clinical Relevance—Young adult, small-breed, neutered dogs that received multiple vaccines per office visit were at greatest risk of a VAAE within 72 hours after vaccination. These factors should be considered in risk assessment and risk communication with clients regarding vaccination.
Most veterinarians agree house cats should be assessed yearly and vaccines –if given at all – should be tailored to an animal’s age, health, and lifestyle. This position is supported by two associations, the American Association of Feline Practitioners and the Academy of Feline Medicine. The Advisory Panel on Feline Vaccines has guidelines for cat vaccination. Feline shots fall into two basic categories: generally recommended, and those recommended for special circumstances. Both of these organizations encourage cat owners and vets to openly discuss all options.
Could you imagine your pediatrician learning similar information, and then suggesting caution about giving too many vaccines at a time?
Pediatricians don’t “get it”
Unlike their animal doctor counterparts, the American Academy of Pediatrics (AAP) endorses universal immunization and strongly encourages only a one-size-fits-all vaccination schedule. The AAP not only assumes all vaccines are necessary; pediatricians assume all children can equally tolerate all vaccines given according to an inflexible schedule.
As many as six doses – and 18 vaccine antigens—can be given at the same time. The Advisory Committee on Immunization Practices (ACIP) recommends that if a dose is missed at the routine two, four and six-month checkups, the injection should be given at the next visit. Every dose is considered to be so essential that the ACIP has created a ‘catch up’ scheduler for children who have missed even one dose.
To by-pass the psychological concerns of parents about giving so many vaccines given at one time, manufacturers have created combination vaccines – such as Pediarix, and Pentacel, and Kinrix and ProQuad – to trick parents into believing that their baby is “only” getting one.
- Pediarix is three vaccines and seven antigens in one shot (DTaP, polio, and Hepatitis B)
- Pentacel is three vaccines and seven antigens in one shot (DTaP, polio, and HiB)
- Kinrix is two vaccines and six antigens given in one shot (DTaP and polio)
- ProQuad is two vaccines and four live viruses given in one shot (MMR + Chickenpox)
Both the ACIP and the AAP overlook a potentially serious problem with combination shots: If a reaction occurs, it is impossible to determine which vaccine antigen caused the side effect. Animal doctors have figured this out. The Association of Feline Practitioners recommends using single dose vaccines because “increasing the number of antigens in a vaccine also increases the probability associated adverse events.”
Rather than individualizing the schedule, most pediatricians seem to have a “vaccinate no matter what” approach to childhood vaccines . The AAP encourages pediatricians to “work individually and collectively to ensure that all children receive all childhood immunizations on time.”
They offer no flexibility and disparage parents at even the suggestion of schedule variation. This includes giving vaccines to children, even when they are sick.
According to the Centers for Disease Control’s (CDC) most recent General Recommendations for Vaccination (2011), there is only one – one! – contraindication applicable to all vaccines: a history of a severe allergic reaction (i.e., anaphylaxis) to the shot in general or to one of the vaccine components. A precaution is a condition where a recipient “might” have an increased risk for a serious adverse reaction. However, the CDC advises that even in the presence of a known precaution, the need for vaccination just might outweigh the risk for an adverse reaction. For example, health-care providers might think that certain conditions, such as diarrhea, minor upper respiratory tract illness, otitis media, previous local reactions and even fever are reasons to withhold a vaccine. The CDC reports that these misperceptions result in “missed opportunities to vaccinate.” In fact, the CDC has gone so far as to recommend a dose of DTaP vaccination, if there is a community pertussis outbreak, even if the person developed Guillain-Barré syndrome after a previous DTaP vaccine.
When animals are sick, most vets err on the side of safety. To minimize the risk of a reaction, vaccines are delayed until the pet is healthy. According to PetEducation.com:
The decision to vaccinate a sick animal should be made on an individual basis. The vet performs a physical examination and possibly obtains laboratory tests to aid in the decision. The decision as to whether to vaccinate an animal who is showing signs of illness should be made on an individual basis. One must consider whether the benefits outweigh the risks.
Not so with children. Routine physical examinations and procedures, such as weights and taking a temperature, are not prerequisites for vaccinating kids who appear to be healthy. The provider should ask the parent or guardian if the child is ill and if the parent says they are healthy, vaccination should proceed.
Ordering Titer Tests
Many vets are concerned enough about the potential for side effects from unnecessary booster shots they order a blood test, called a titer test, to measure the level of an antibody in the blood. A titer is reported as a ratio of one to a number. The higher that number, the better. For example, a titer of 1:5 is a low titer, and generally implies a susceptibility to disease. A titer of 1:1,000 is a very high titer, and implies immunity. It is generally accepted that a high titer indicates further vaccination is unnecessary.
Titer tests are available for children and adults too. You can order these tests directly and privately, through my affiliate link with DirectLabs.com. If your titer is high, you can take the report to your pediatrician – and your boss, school nurse or college admission board – and have the information you need to refuse the next round of vaccines. Be sure to tell your doctor that if your veteranarian uses titer tests, he should use them also!
Vets vs Peds: An Interesting Comparison
Unlike the AAP which routinely denies any connection between vaccines and adverse events, the American Veterinary Medical Association concludes that vaccines can cause problems and should be individualized. The following is an excerpt of their policy:
“Veterinarians should recall that animals must be physiologically healthy and immunologically competent to respond to the vaccine. When serological titers are used to help determine the vaccination/protection status of an animal, veterinarians should make sure these data have been clinically correlated to host-animal protection studies for the specific diseases and species being tested. For most common vaccine antigens, the correlation between serological response to vaccination, long-term serostatus, and protection in the host animal has not been adequately established. The lack of these data often precludes practitioner’s ability to make well-informed vaccination decisions based on serostatus alone.
Vaccination and revaccination programs, for preventive health care, should be designed to maintain the health of the animals and public health while minimizing adverse effects. Veterinarians should evaluate the risk/benefit ratio to vaccination before implementation on any individual patient or group of animals. Vaccine protocols must be developed in consideration of patient husbandry, endemic disease, geographical location, patient disease susceptibility and immune status. Other factors in the establishment of vaccine management protocols are the general health of the patient, the vaccine antigen/adjuvant combination, methods of administration and concurrent drug or chemical use. Though vaccine products are continually improving, scientific understanding of vaccine pharmacology and immunology remains incomplete with respect to the prediction and prevention of any/all potential adverse events.
Veterinarians should recognize that failure to use vaccines according to manufacturer-labeled directions may result in potential liability to the veterinarian in the case of an adverse event.
It appears that veterinarians are more prudent about vaccination than their pediatrician counterparts. Could this precaution, at least in part, be due to the fear of liability? Pediatricians have none; they are protected at every level by the Nation Vaccine Injury Compensation Program. Could it be that vets love their patients more than pediatricians? Probably not, but it’s time for pediatricians, the AAP, the CDC, the ACIP and all other organizations involved with human vaccination programs to acknowledge that vaccines have risks and can cause serious harm, including death – and that these events are not rare.
If animal doctors can work with owners to individualize vaccination schedules, human doctors need to do the same. Parents, demand the standards of care for your children just be at least as good as it is for your pets.
Originally posted on Huffington Post, April 16, 2010. This version has been rewritten and updated.