Introduction

This is a 2-part blog on Bordetella pertussis (B. pertussis) a disease also known as whooping cough. Part 1 will talk about the pathophysiology and management of B. pertussis, whereas part 2 will talk about the ethics surrounding the case study. I really enjoyed this case study, especially when ethics are involved. This is part 2 with a focus on ethics.

Whooping cough, Bordetella pertussis, is an extremely contagious bacteria that is transmitted through air droplets or physical contact (1). The outcome of getting whooping cough may cause deaths in high-risk groups such as infants (1-3). After numerous trials between 1923-1924, the vaccine proved to have some protection, and by the early 1940s, the vaccine was widely distributed and endorsed by the American Academy of Paediatrics (4). The vaccine proved to be effective in reducing deaths (1,3,4); however, childhood immunisation is a delicate topic to those who are opposed especially when it involves a child’s autonomy as well as the parents’ rights. There are many ethical issues regarding vaccines and infants as they cannot give adequate consent and have to rely on the parents. Approaching this challenge may be difficult and tedious, and often healthcare professionals may approach this topic with too much information or emotions. Building rapport and communication regarding parents who are against vaccination is key in managing the issues.

Janet, a mother, has brought her 10-month-old infant into the hospital. She mentions that the baby has been unwell for several weeks, starting with what she thought was a cold, with a runny nose and dry cough. However, in the past two weeks, a more definite cough has developed, and the baby has had to be kept home from Day-care. When checking the baby’s history, you notice that he has not received his standard childhood immunisations. When you mention this to the Mum, she states that she is very “anti-vaccination due to all the toxic products that are included in vaccines today”. Tests confirm your suspicions that the baby has whooping cough.

Ethical issue

The primary and most prominent ethical issue, in this case, would be the patient’s lack of protection of diseases that can be avoided or at least a dampen version of the disease with tolerable and less life-threatening symptoms through the use of vaccines. However, the patient’s age provides some challenge as they are under 18-years of age or must at least achieve a certain age to consent.

Should the lives of human beings that cannot make those decisions be in the hands of those who can? It depends. In this situation, parents should make the best decisions for their children, which in a way is similar to doctors making decisions over their patients. This is called beneficence which describes the obligation to do good. Of course, there are exceptions when the law is involved, and a patient has made clear cut decisions on how they want their lives to be handled such as palliative care (in this case it is called autonomy, which is respecting their decisions). These are patients who can make decisions. A patient who is 11 months old has to rely on their parents’ decision, but what if their decisions do not achieve the best outcome as clearly demonstrated in this example? Should the child be prevented from going to schools, participating in sports and other activities if his vaccines are not up to date? Should children be punished by their parents’ decisions, or should the parents be punished if it is proven that the disease could have been avoided?

Fortunately, doctors and other healthcare professionals are in an excellent position to provide the best logical answers backed by decades of literature on health topics. The influences of doctors can help in educating and providing the right/best choices for those who are not sure or are against it. From this example, it is clear the mother (we are not sure where the other family member stands on this decision) has chosen not to vaccinate her child even if the literature demonstrates strong evidence of preventing certain diseases through vaccination. Should we assume that the mother is purposefully putting her child in harm’s way? Clearly not. A mother should love her child and always seek the best outcome for their children through the decisions they have made. Hence, through her point of view, we can deduct that vaccines cause more harm than not taking any vaccines. The possibility that the “right way” of being immune to diseases is to get the disease when you are young just like they did back in the older days should also be explored. It was found that some want to enjoy the heard immunity without exposing their children to vaccines side effects; this is called free-riding (12). As doctors, it is vital not to blame or guilt but to understand our patients. We should understand why she has chosen not to take the vaccine approach for her child, and surprisingly most of the time, they have reasons that can be explained.

For example, a reoccurring reason for parents not allowing their children to be vaccinated comes from doctors not explaining adequately the risks vaccines can cause. This speaks about nonmaleficence where there is an obligation to do no harm but sometimes what may bring benefits may bring some harm. Vaccines can cause harm and have been shown in some instances to do harm. However, it is about context. The whooping cough vaccine has shown to cause seizures in 1 in every 14 000 children (13), and seizures can be treated. Before the whooping cough vaccine, 200 000 children would be sick per year in the United States with a death rate of 4.5%, that equates to 9 000 deaths per year (1,3,13). Today in a robust healthcare system, the death rate from serious complications of B. pertussis in infants that were hospitalised is 1% (14). The main point is that parents trusted the vaccine and may not have been told about potential side effects or its effectiveness (called waning immunity), and when something does go wrong the vaccine thus takes the blame. These personal stories are then shared, blown out of context and influences people not to vaccinate. It is vital to disclose as much information and explain that vaccines save lives but that there is a slight chance of side effects just like any other medicines.

It is our ethical duty to do good and do no harm, and as future healthcare providers, we are in the position to educate and advise our patients. It would be unethical to give vaccines to a child even though it is proven to be the better choice in terms of mortality or “do good for the patient and society”. As a result of this case, the doctor could explain to the mother that her son could have avoided B. pertussis or at least have milder symptoms if he had his vaccines. So far, it is not shown if the patient will have complications, end up at the hospital and could potentially die, which is a real outcome. Another major point that should be mention is the other children who were exposed to B. pertussis from Day-care. Some of these children would have been immunised, some may have not or partially and some couldn’t due to health reasons (who are protected solely on herd immunity, hence a society that takes vaccines diligently). These children would have become sick or asymptomatically contagious and spread B. pertussis to their family members to which some members may have many complications such as chronic obstructive pulmonary disease (COPD) and may die from this consequence.

Resolution through good communication

It is vital for healthcare professionals to speak to the patient’s parents and assess the father’s stance on vaccination. It is essential to be honest with the parents and suggest the right and safest course of action, which would be in making sure the patient has all his vaccination. It is not recommended to use blame or guilt but rather listen to their worries, respect their fears and understand the reasons why the mother prefer not to use vaccines. Hence, respect their autonomy.

It is advised to have extended and comprehensive consultations to address each issue and bear in mind the power difference between doctors and patients, especially when parents hear about vaccines but were never told about potential side effects. If there is a communication problem, suggest translators and use the talk-back method of teaching. Involving both parents to make a decision builds trust and rapport. The healthcare professional own emotions need to be turned down and avoid using too many facts or trying to debunk myths as it may amplify their beliefs of propaganda. Motivational interviewing strategies may be utilised. Assess where in the transtheoretical model of change they are at and aim for the next step.

Explain that chemicals put together can make them safer as they are more stable just like oxygen and hydrogen makes water, then compared to when oxygen and hydrogen are alone (such as O2 and H2) to which they are combustible or is seen in rocket fuel. Explore the idea that dangerous chemicals are at a significantly much lower level and cannot cause harm. For example, formaldehyde in vaccines is only 0.1 mg per dose, whereas an apple has 6 mg. Aluminium, the third most abundant element in the earth’s crust, occurs naturally in food such as potatoes, rice, grapefruit or is even found in breast milk. It is all about the safety and natural level of certain compounds, for example, drinking too much water can cause hyponatremia and in some cases have caused death. Is water bad for you? Of course not, it is all about context and perspective.

Subtly demonstrate the effect of not using vaccines such as the whooping cough development in the patient and the harm it can have on other people in society, especially those who cannot take vaccines. A relevant point is to explain that all medicines carry a risk, but the injury from getting from vaccines is much lower than the injuries of the disease itself.

Moving on from there

The reality of not vaccinating a person from such an infectious disease could potentially put in danger 100s of other people in society. What has been done, has been done. Healthcare professionals can only communicate effectively by educating and explaining that vaccines save lives and that the patient should be on a catchup vaccine plan. It is vital to keep a balance between autonomy and respecting parents’ rights and the child’s health as well as the greater good for society and those who cannot be vaccinated. Parents may not agree or act against their beliefs, but long rapport that is built on trust can slowly move them towards the next stage of the transtheoretical model of change. Unfortunately, this takes time and may further expose other people in high-risk groups. In managing the patient and the family, honesty and communication are key.

Published 10th October 2020. Last reviewed 1st December 2021.

Reference

1.  Liang J, Weinbaum C, Moro P. Pertussis. In: Hamborsky J, Kroger A, Wolfe C, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Washington, D.C.: Public Health Foundation; 2015:261-278. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pert.pdf. Accessed September 12, 2020.

2.  The Royal Children's Hospital General Medicine and Respiratory and Sleep Medicine departments. Whooping cough. The Royal Children’s Hospital Melbourne. https://www.rch.org.au/kidsinfo/fact_sheets/Whooping_cough/. Reviewed April, 2019. Accessed September 12, 2020.

3.  World Health Organization authors. Pertussis. World Health Organization. https://www.who.int/immunization/monitoring_surveillance/burden/vpd/WHO_SurveillanceVaccinePreventable_16_Pertussis_R1.pdf?ua=1. Updated September 5, 2018. Accessed September 17, 2020.

4.  Cherry, JD. The History of Pertussis (Whooping Cough); 1906–2015: Facts, Myths, and Misconceptions. Curr Epidemiol Rep. 2015;2:120-130. https://doi.org/10.1007/s40471-015-0041-9.

12.  Hendrix KS, Sturm LA, Zimet GD, Meslin EM. Ethics and Childhood Vaccination Policy in the United States. Am J Public Health. 2016;106(2):273-278. doi:10.2105/AJPH.2015.302952

13.  U.S. Department of Health and Human Services. Whooping cough (pertussis). Vaccines government. https://www.vaccines.gov/diseases/pertussis. Reviewed January, 2020. Accessed September 17, 2020.

14.  Centers for Disease Control and Prevention authors. Clinical complications. Centers for Disease Control and Prevention. https://www.cdc.gov/pertussis/clinical/complications.html. Reviewed October 25, 2019. Accessed September 20, 2020.

ADDITIONAL SOURCE OF INFORMATION:

Centers for Disease Control and Prevention authors. Pertussis frequently asked questions. Centers for Disease Control and Prevention. https://www.cdc.gov/pertussis/about/faqs.html. Reviewed November 18, 2019. Accessed September 17, 2020.

Centers for Disease Control and Prevention authors. Postexposure Antimicrobial Prophylaxis. Centers for Disease Control and Prevention. https://www.cdc.gov/pertussis/pep.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fpertussis%2Foutbreaks%2Fpep.html. Reviewed November 18, 2019. Accessed September 15, 2020.

Centers for Disease Control and Prevention authors. Treatment. Centers for Disease Control and Prevention. https://www.cdc.gov/pertussis/clinical/treatment.html. Reviewed October 25, 2019. Accessed September 15, 2020.

Centers for Disease Control and Prevention authors. Whooping Cough Vaccination. Centers for Disease Control and Prevention. https://www.cdc.gov/pertussis/vaccines.html#clinical-information. Reviewed January 15, 2019. Accessed September 15, 2020.

European Centre for Disease Prevention and Control. Expert consultation on pertussis. Barcelona: European Centre for Disease Prevention and Control; 2012:1-11. Available at: https://www.ecdc.europa.eu/sites/default/files/media/en/publications/Publications/pertussis-meeting-2012.pdf. Accessed September 12, 2020.

Hooker C. How to cut through when talking to anti-vaxxers and anti-fluoriders. The University of Sydney. https://ses.library.usyd.edu.au/bitstream/handle/2123/16350/how-to-cut-through-2017.pdf?sequence=1&isAllowed=y. Published February 15, 2017. Accessed September 19, 2020.

Mayo Clinic authors. Whooping Cough. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/whooping-cough/diagnosis-treatment/drc-20378978. Reviewed October 9, 2019. Accessed September 15, 2020.