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I think about children and vaccines more than the average person.  I’m an emergency medicine physician, and a parent’s decision to vaccinate his or her child affects my job every single shift.

Children get fevers frequently.  Current research suggests that the average child not in daycare will have between 6-8 fevers per year between the ages of 0-3, and children in daycare will average 10-12 fevers per year.  Fevers can be scary, and those children and frightened parents often end up in the emergency room.

Every visit for a febrile child begins with a conversation with the parents and an examination of the child.  As long as the child looks well–meaning he or she will interact, make eye contact, and act appropriately for his or her age–the next most important question is about the child’s vaccination status. Depending on the parents’ decisions on vaccination, the visit then can follow one of two paths.

For children who are fully vaccinated and over six months of age, I search for a source of the infection based on their symptoms; if they are coughing or have other signs of a respiratory infection, the child gets a chest x-ray.  Young girls and uncircumcised males are at higher risk for bladder infections, so we usually do a urine test.  If those are all negative, we usually send the child home with no medications and the expectation that the fever is caused by a virus and will soon go away.

Unvaccinated children, however, require much more testing.  Most practice guidelines recommend multiple blood tests, which require an IV, urine testing, a chest x-ray, and, depending on the child’s age and other risk factors, possibly a lumbar puncture (a.k.a.  spinal tap).

Based on those results, children are sometimes then treated with antibiotics via another injection, and then have to see their primary doctor within twenty-four hours to continue the antibiotics and often have more blood tests done.

This disparity in how children are evaluated in the ER is based on very basic differences in how high of a risk children are at for invasive bacterial infections.  For children who are unvaccinated, some estimates as high as 5-8%* of them have a serious infection in their bloodstream (bacteremia) or around their brain (meningitis).  For children who are fully vaccinated, the risk of bloodstream and brain infections is less than 0.001%.

I fully support parents’ rights to choose not to vaccinate, but there are consequences to that decision.  I have had many conversations with parents in the middle of the night when their child has a fever and had to explain to them that because of their decision to not vaccinate, research indicates that their child is at a significantly increased risk for life-threatening diseases, and so will need invasive testing in the ER.  It will take hours, and it will hurt their child.  I tell them that the diseases we vaccinate against aren’t just nuisances; they kill and maim children every day, and they are almost completely preventable by vaccination.

I tell parents that I have worked in several developing countries, and I have seen children disfigured by diseases that we only read about in history books.  I’ve seen babies die of diseases that in the U.S. we don’t even think about as a cause of illness because vaccination has nearly eliminated the illness.  However, these illnesses are starting to make a comeback because of the anti-vaccine movement.

I also tell them that as a parent of two boys, I carefully research every vaccine and medicine that my children are given.  I read the medical journals on the topic, and examine the evidence for myself about all of the controversies about thimerosal and autism and invasive disease.  Then I tell them that after many hours of studying the best research available, I am first in line to have my children vaccinated every time they are due.

Dr. Torree McGowan, MD, graduated from Oregon Health and Sciences University.  She is a Fellow of the American College of Emergency Medicine and is a practicing emergency physician in California.  She is the proud mother of two little boys. 

* The 5-8% number is based on pre-vaccine era numbers of children who presented to either ERs or pediatricians who had fevers higher than 102.2F (39C). Prior to routine HIB vaccination, the number was around 8%, and then fell to around 5% after HIB vaccinations. That number has continued to fall since 2000, when the pneumococcal vaccine was introduced, to the current state, which is about a 0.9% occult bacteremia rate, most of which are Strep pneumonia isolates. Now that the new Prevnar vaccine has been introduced in the past 2 years that has 13 serotypes, we expect that number to fall even further. The true rate of disease for unvaccinated children in the US is probably lower than the 5-8% estimated from pre-vaccine era studies because of herd immunity, but those are the numbers we typically use to estimate risk for children who are not vaccinated, simply because it’s the best data we have. [See abstracts #1, #2, and #3.]

The number for the fully vaccinated risk of bacteremia and meningitis is based on 7-9% progression from bacteremia to meningitis of the 0.9% of children with occult bacteremia (0.009*0.7 = 0.00063 or 0.063%).  The progression from occult bacteremia to meningitis may be even lower, because 80% of the meningitis was caused by pneumococcus, which we now vaccinate against.

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