Vaccination: refuting the refusals

A few months ago an outbreak of 19 cases of measles occurred in a small community in British Columbia. Almost all of the cases were children whose parents had decided against immunization, for philosophical reasons. The outbreak was traced to 2 index cases in Alberta, siblings aged 2 and 3 years, who had recently returned to Canada from Bolivia, where the exposure probably occurred. These 2 children came into social contact with the other children while they were attending, along with 1500 other people, an outdoor concert in Saskatchewan.1 Large outbreaks of measles still occur in communities where vaccine coverage is low. Between November 1999 and January 2000, 103 cases were reported in a religious community in the United Kingdom, and 2300 cases, with a 20% rate of serious complications and 3 fatalities, were reported in the Netherlands during the last 9 months of 1999.2

The reasons for vaccination refusal are complex, varied and not infrequently wistful. They include religious or philosophical beliefs, concerns about safety and efficacy, beliefs that vaccine- preventable diseases do not pose serious health risks, objections to mandatory programs and excessive government interference and objections to immunization as being ”unnatural.”3 Some of these objections were raised in the 19th century, when religious convictions, suspicion of new technology and objections to government intrusion fuelled large-scale resistance to smallpox vaccination.4 These days, as we know, immunization programs have become a victim of their own success. It is worth reminding patients that (to take only one example) the complications of measles include otitis media, pneumonia, croup, diarrhea and encephalitis, and that the fatality rate is 2‐3 per 1000 cases.5

There are some readily available resources that clinicians may find useful in their efforts at persuasion. The Canadian Immunization Guide contains a succinct table comparing the risks of the disease with the risks of vaccination (www.hc-sc.gc.ca/hpb/lcdc/publicat/immguide/comp_e.html), and the Canadian Immunization Awareness Program summarizes common misconceptions about immunization on its question-and-answer Web page (www.ciap.cpha.ca/q&a.htm). Patient beliefs that vaccination is ”unnatural” may be particularly challenging for physicians, who are technologists and interventionists by training, more apt to maintain the motorcycle than to leave it to Zen.6 As Robert Pirsig demonstrated in his best-selling book, the dialogue between the motorcycle maintainer and the antitechnologist is fraught with irritation. Debating with patients who refuse vaccination may sometimes be futile. But to counter the surrender to nature of the anti-immunization lobby we can at least offer Pirsig‚s insight:

I disagree with them about cycle maintenance, but not because I am out of sympathy with their feelings about technology. I just think that their flight from and hatred of technology is self-defeating. The Buddha, the Godhead, resides quite comfortably in the circuits of a digital computer or the gears of a cycle transmission as he does at the top of a mountain or in the petals of a flower. To think otherwise is to demean the Buddha — which is to demean oneself.6 — CMAJ