On Patient Safety: The Importance of Vaccinations—Avoiding the Mistakes of the Past

The proportion of young children in the United States who do not receive vaccines has increased fourfold since 2001 [19]. This disturbing trend, along with the even more concerning news that some 100,000 children in the US younger than 2 years of age now are entirely unvaccinated [19], will grab our attention for a few days and then exit our consciousness without provoking much in the way of action. However, the general medical community—and more specifically the orthopaedic community—should respond strongly to these developments.

The proportion of schoolchildren now exempted from immunization requirements likewise is on the rise, and now stands at 2.2% [14]. Other evidence shows that the United States has developed both urban and rural “hot spots” where the immunization rate has fallen below the 90% required for the community to benefit from herd immunity [15, 17]. This puts the safety of additional children, including those with cancer and other forms of immunosuppression, at risk. We are moving forward into the past, a past in which children died needlessly from preventable infectious diseases.

The medical community cannot be passive here. Although in 2000 the CDC declared that measles had been eliminated in the United States [6], this has proven not to be true. As the proportion of children immunized has dropped, the number of children with measles has surged [1]. A large measles outbreak in Minnesota last year affected more children in that one population than normally contract the illness across the country in a typical year [12]. Although the outbreak subsided, every child in the outbreak suffered needlessly.

What can orthopaedic surgeons do to respond? Plenty. First, as respected medical professionals, we should lobby our state legislators to reduce the numbers of nonmedical exemptions from vaccinations required to attend school. Changing these laws can have a profound impact. After the 2014 Disneyland measles outbreak, California enacted a law banning both religious and philosophical exemptions [16] resulting in an all-time high for kindergarten vaccination rates for the 2016-2017 school year [2]. Many of us regularly see children as patients; we cannot be afraid to speak up for their health and safety. As a seasoned veteran of these struggles over immunization, James J. Laughlin MD, Assistant Clinical Professor of Pediatrics for the Indiana University School of Medicine tells me, “It can be extremely difficult for educated and concerned but nonmedical consumers to interpret all the misinformation available; that makes our role as a trusted source of evidence-based information all the more important.”

Second, make immunization history a regular part of patient intake in our clinics. In order to improve safety for all their patients, some pediatricians now refuse to accept nonimmunized children into their practices [8, 10, 18]. I don’t suggest we follow this example for two reasons. First, it could limit children’s access to orthopaedic care, and second, delivering information regarding the seriousness of preventable childhood illnesses has been shown to be a potentially effective strategy for increasing parents’ willingness to vaccinate [11, 13]. Therefore, I recommend that we, as a trusted medical resource, engage in thoughtful and friendly conversations with parents of unimmunized children. This may help them to decide to get their children vaccinated or, at least, reinforce the information given by their pediatrician or family physician.

Third, encourage all patients older than 6 months to get the influenza vaccine. According to the CDC, the vaccine is helpful to children, working age people, and the elderly [5]; in 2016-2017, 85,000 influenza-related hospitalizations were avoided because of the vaccine, and it prevented 5.3 million cases of the flu [4]. Pediatric influenza immunizations reduce pediatric ICU visits by more than 70% [9], and studies show the vaccine can reduce a healthy child’s risk of dying from influenza by 65% [3].

Fourth, we should obtain all immunizations recommended by the CDC for healthcare workers or those required by hospitals where we practice. This will both improve our safety and reduce the infectious disease risk of those individuals under our care. And finally, we should continue to strive to practice evidence-based medicine while minimizing our own biases and emotion-based decisions. We can’t ask our patients to follow the evidence if we are unwilling to do so ourselves.

Immunizations are among the most-important medical advance in world history. However, in our current era of scientific mistrust and belief in the primacy of personal opinions, we cannot be complacent. Vaccines have improved the lives of hundreds of millions of children. We should do what we can to ensure that all our patients continue to receive them.