Suspicion of vaccines among those who should know better

I realize I repeat this a lot, but it bears repeating a lot. Vaccines are, without a doubt, one of the greatest advances in health care devised by the human mind. Arguably, vaccination campaigns have saved more lives and prevented more suffering and death than pretty much any other medical preventative intervention ever invented. I realize that I tick off antivaccinationists when I say that, but I don’t care. Actually, I do care. I kind of like ticking off antivaccinationists using science. You didn’t think I’ve been blogging for seven years purely out of a sense of duty to humanity, science, medicine, and ethics, did you? Maybe 90% duty, but I have to have a little fun as well.

Because vaccines have been so successful, for the most part health care professionals tend to view them in much the same way as most people view clean water and pure food; i.e., as unabashedly good and healthy things. And, except in rare instances, they are. Unfortunately, as we in medicine have demontrated since the time of Semmelweiss, we aren’t always the best at doing what’s best for our patients, such as washing our hands before seeing patients, but that’s not so much out of opposition to handwashing or a belief that handwashing doesn’t do any good. Rather, it’s usually more due to pure laziness or carelessness. Unfortunately, all too often, the same cannot be said of health care professionals when it comes to basic vaccinations that protect both us and our patients, in particular the influenza vaccine. A friend of mine, Mark Crislip has a word for such health care workers (and, make no mistake, this group includes doctors, nurses, and many others): Dumb ass. (Or, for those of you who don’t have access to Medscape: Dumb ass.)

Yes, I realize that it’s considered exceedingly gauche these days to be so judgmental, so much so that even Orac can’t help but cringe just a little bit at Mark’s judgment. At the same time, I know he’s right. Also remember: Mark is not calling patients who refuse recommended vaccinations for themselves or their children dumbasses. He’s calling health care professionals who refuse recommended vaccinations by that moniker. The reason should be obvious. First, health care professionals should know better. They really should. They have no excuse not to know better. Yet there is a cadre of doctors, nurses, and others who resist doing the right thing. Second, health care professionals have a duty to their patients to protect them from harm whenever possible, and, like handwashing between patients, certain vaccinations in certain specialties are part and parcel of protecting patients. This is particularly true where I work: A cancer center. There are a lot of immunosuppressed chemotherapy patients around who could easily die if they caught influenza.

Mark’s admonitions were in my mind as I came across this post on Gaia Health (a website run by a homeopath) entitled Nurses Don’t Trust Vaccines, So Study Researchers Show Them No Respect. The title, as is common with antivaccinationists, is overwrought. In fact, when I read the study by Baron-Epel et al entitled What lies behind the low rates of vaccinations among nurses who treat infants?, I didn’t think the authors were disrespectful at all. (In fact, all they noted was that many of the nurses who took part in facilitated focus groups as part of the study expressed antivaccine views, and that is undeniable. The quotes are there, as you’ll see.) In the meantime, homeopath Heidi Stevenson is very irate at this study:

The researchers had no interest in considering whether the role played by nurses as the primary contacts with patients might give them a valuable perspective on the issue. Instead, their only interest was in figuring out how to counter the nurses’ views. In other words, the presumption was that nurses are less intelligent and less capable of making rational decisions than they are.

Heidi says that as though it were a bad thing!

I keed, I keed, of course, but only a little. The implication was not that nurses are less intelligent; the implication of the study was that health care professionals can fall prey to misconceptions about vaccines that clearly derive from the antivaccine movement. That, too, is undeniable. (Look at Dr. Bob Sears if you don’t believe me. Of course, Dr. Bob strikes me as not the sharpest knife in the drawer; so maybe he’s a bad example.) In any case, the impetus for this study was a pertussis outbreak in an Israeli hospital in 2010:

In the summer of 2010 pertussis was diagnosed among 20 nurses and physicians in obstetric and neonatal departments in a large hospital in Haifa, Israel. The Ministry of Health (MOH) recommended immunizing the HCWs in these departments, and in two nearby hospitals. In addition, nurses working with infants in the Mother and Child Healthcare Centers (MCHCs) in this district were also asked to immunize themselves. After three months only two percent of the MCHC nurses did so.

The aim of this study was to identify the barriers and reasons why these nurses did not vaccinate themselves against pertussis despite the fact that the pertussis vaccine is the vaccine these nurses administer to infants every day. These barriers may not be specific towards the pertussis vaccine and may help understand non-compliance towards other vaccines.

A pertussis outbreak among 20 nurses and physicians? In obstetric and neonatal departments? This is a no-brainer! Health care professionals taking care of infants in that hospital needed to be vaccinated to protect themselves and their patients. Not to do so would be an epic failure at both goals. Yet, epic fail is what there was at those hospitals. only two percent of the nurses did.

To try to understand the reasons for noncompliance, focus groups were interviewed, and a qualitative analysis carried out on the nurses’ responses. This qualitative analysis revealed several key themes used by the nurses as their justification for not wanting to receive the Tdap vaccine, even though they administer pertussis vaccine to infants. Here are the main themes, with brief explanations, random Orac snark, and, for some of them, sample quotes from the nurses:

  • Lack of trust in the health authorities. Much of this was related to the H1N1 pandemic the year before, which, because the pandemic wasn’t as serious as had been feared, led to the nurses thinking that health authorities overreacted.
  • Treatment of nurses by the employer. Nurses were unhappy at what they perceived as being badgered to be vaccinated. Sample quote: “They should treat us like human beings.” “…we were threatened, we got multiple emails asking who got vaccinated and if not why not…”
  • The right for autonomy. This is the typical resistance we see to being told what to do. It’s the same sort of attitude that underlies resistance to the individual mandate in the Patient Protection and Affordable Care Act. Some of the reactions were quite clear in this respect: “One nurse in the hospital got pertussis, and infected someone- or not- don’t know. So then ‘wham’ all the nurses have to get immunized, so no one got immunized and they are right!…what are we?- in Soviet Russia?…on principle I am not getting vaccinated this year.” Because, I suppose, requiring this nurse to do the responsible thing for herself and her patients is just like the authoritarian regime that was the Soviet Union, and being stubborn is the same thing as being principled. In this, these nurses sound like physician members of the AAPS, who seem to think that physicians should be allowed to do anything they please, damn science and science-based guidelines. “Health freedom” infects nursing.
  • Mistrust of health information. Sample quote: “…you can’t brain wash us, they expect us to forget what they said three months ago or a year ago and start again, part of what we did was not so good, now we do something else. …you can do that at work but not in my private life, I can’t…”
  • The split between professional role and personal life. This one is rather disappointing. Nurses are professionals, just like physicians. There are responsibilities that come with being a professional and that also intrude into one’s personal life. That’s part of what it is to be a professional.
  • Fear of side effects. The authors observe, “The nurses reported on their experiences of side effects of vaccines. They felt that the risk of contracting the diseases and the severity were not worth the risk of being injected with a vaccine that was not in use long enough to know what the side effects were. This was directed towards both influenza and pertussis vaccines, and they felt the authorities were using them as guinea pigs.” Never mind that the pertussis vaccine has an excellent safety record.
  • Risk perception. Many of the nurses didn’t think they were at risk for pertussis, even though there had just been an outbreak. Sample quote: “I think that at my age I should be immune to pertussis, I am sure I was exposed during my life, I am not ten years old, and not twenty, and also, how many nurses had pertussis and infected others?”

Perhaps the most disturbing aspect of this entire study was this:

Interestingly enough, the fact that they themselves can infect the infants that they come in contact with came up only once in all the discussions, and was not discussed in depth. This issue seems not to bother them and they do not see the ethical problems related to the possibility of their being infectors. There is a need to increase the nurses’ awareness of the unethical aspect of not being immunized and increase the perception of themselves as transmitters of diseases.

Sadly, I’ve seen such attitudes among physicians as well. Part of it, I think, is a sense of entitlement in which health care professionals convince themselves that they are, in essence, invulnerable and would never endanger their patients. The bottom line from this study, unfortunately, is this:

The nurses expressed antivaccinationist ideas and these may be preventing them from being immunized as recommended. Emotions and attitudes such as fear of the vaccines, mistrust in the health authorities, a demand for autonomy, low risk perception, perceiving themselves as private persons and not only nurses, in addition to not perceiving themselves role models, lower the compliance with vaccine guidelines for HCWs. These attitudes and emotions may influence their actions toward other vaccines in the future. Stemming from this study an ethical problem is raised: to what extent should the health authorities give autonomy regarding vaccination to HCWs working with vulnerable populations? Additional research and interventions to increase trust between nurses and the authorities and knowledge regarding vaccines is needed.

I’ll say. And, if Dr. Jay Gordon and Dr. Bob Sears are any indication, physicians shouldn’t be too smug. We’re just as prone to antivaccinationist nonsense as these nurses apparently were.

Yes, this was a small study. Yes, it was not in any way comprehensive. However, it does raise some disturbing issues. If nurses in a pediatric unit, whose jobs it is to administer vaccines, can be so easily swayed by antivaccine views to the point that, even after an outbreak of pertussis they refuse to be vaccinated, how, then, do we combat antivaccine views. Science isn’t enough; these nurses had access to the science and rejected it because of mistrust of health authorities and an unprofessional lack of concern over whether they themselves could be vectors to infect the infants they take are of. These are exactly the nurses who should most readily understand the importance of vaccination, just as pediatricians like Dr. Bob Sears and Dr. Jay Gordon are exactly the medical specialty that should understand that the vast preponderance of existing scientific and clinical evidence does not support the belief that vaccines cause autism. Yet, there they are, promoting (in the case of Dr. Gordon) or insinuating (in the case of Dr. Sears) that vaccines do cause autism. Indeed, that brings me to one part of this study where our homeopath might have a little point: Why weren’t physicians studied or interviewed?

Be that as it may, clearly, we have a problem in our own professions. As Mark Crislip would put it, we in the health care profession have far too many dumb asses in among our ranks.