Naturopathic Perspective


I want to share my approach concerning immunization in primary care as a naturopathic doctor. Just like any intervention, as a licensed healthcare provider, my care must be unbiased, researched, and – most importantly – provide a safe place for my patients to share their thoughts and concerns. Dealing with immunization is like dealing with any intervention. As of 2019, I am one of the few (though many more to come) naturopathic doctors in British Columbia (BC) who have completed the BC Centre for Disease Control (BCCDC) immunization course, and I am certified by the regulatory college to administer vaccines in my office. Our clinic follows the immunization policy that has been set forth by the regulatory office.1


One of the main reasons I made the decision to offer this medical intervention in my office was to create a space for people to discuss their situations and express their concerns, and for us to discuss statistics, risks, and ways to optimize patients’ healthcare outcomes. Over the past decade I have noticed that the culture around vaccination has changed and that families are finding it difficult to simply have a rational, transparent conversation that is not fueled by anger or fear.


My clinical experience and readings on several public forums has proven to me just how many people are avoiding the conversation around vaccination simply because of how uncomfortable it is. One of the most common statements I hear from my patients is, “My doctor makes me very uncomfortable when I bring up any questions around vaccines.” Or: “All I want is to ask questions. Please do not judge me or shame me, either way, on my decision.” The moment a person feels uncomfortable or scrutinized is the moment that a movement of hesitancy and avoidance is born.


Measles & Seroconversion


In Canada, the decision to vaccinate is a personal choice. In British Columbia, the BCCDC has stated that the decision to vaccinate or not is the right of the individual. During my certification course for administering vaccines, the BCCDC stated, “Individuals have the right to choose, or refuse, immunizations that are available to them. They retain the responsibility of their own, or their child’s, health.”


In 2019 there has been increased attention on measles cases. As of May 6th, 29 cases had been reported in BC,2 and many more have probably gone unreported due to the fact that measles is a very contagious virus. This has resulted in extra discussion surrounding vaccination rates, clinical consequences of contracting measles, herd immunity, and timing of the vaccine.


As a result of this focus on measles cases in this province, my vaccine consultations have increased exponentially. It is clear that naturopathic doctors play an important and unique role in this area. Those who are certified by the regulatory college to administer vaccines can offer something unique – the space and time for navigating the sea of questions parents have.


One of the main topics I talk about with patients is seroconversion. What I mean by this is: did their body make a high-enough threshold of antibodies from the antigen in the vaccine to produce immunity? And do they still have immunity? How can we determine this? I ask my adult patients to do titer testing – which I offer in my office – so we can determine the immunity of our community. In addition, testing enables me to check for acute active infections of measles. We are well versed in how titers work, since we routinely use titer testing for pregnant women against rubella and hepatitis B to see whether they have mounted immunity to these 2 viruses, are current active carriers, or have no immunity at all. This kind of testing can be used at the community level or even on a global scale.


Vaccination Side Effects & Efficacy


One typical question patients ask me is, “Do vaccines have side effects?” I tell them that there is potential to have a side effect with anything I administer, from pharmaceutical prescriptions to even supplements. The side effects of vaccines are usually mild and short-lived, but in rare cases more severe adverse events may occur. In Canada, there is both active surveillance and passive surveillance of vaccine adverse events. Active surveillance for adverse events or vaccine failures in children following immunization is carried out by IMPACT (Immunization Monitoring Program ACTive), a pediatric, hospital-based, national active surveillance network. IMPACT works to achieve nationwide vaccine safety monitoring and disease reporting. Passive surveillance is carried out by CAEFISS (Canadian Adverse Events Following Immunization Surveillance System); a voluntary reporting system in which reports by AEFI (Adverse Events following Immunization) are collected by public health authorities in provinces and/or territories and then forwarded for collation. Although the reporting is voluntary, some provinces and territories (Ontario, Quebec, Saskatchewan, Manitoba, Nova Scotia, and New Brunswick) have laws requiring that healthcare professionals report AEFI.3


As a naturopathic doctor in BC who administers vaccines, reporting is part of my responsibility. To date, I have not had to report any vaccine-related adverse events.


Through my experience, I have noticed a missing piece to vaccination: how to optimize vaccination. My career working with vaccines started overseas, where a select number of vaccines are mandated. As a result, I found myself working with parents on how we could potentially optimize the efficacy of a vaccine by improving the immune response. One example of this that has become apparent to me is based on the Centers for Disease Control & Prevention (CDC) surveillance reports of pertussis cases in the United States, which examined full, partial, and unvaccinated individuals.4 As was discussed in an article published by the Journal of the Pediatric Infectious Disease Society, in 1997 the DTP vaccine was altered from a whole-cell pertussis (DTwP) vaccine to an acellular pertussis vaccine (DTaP).5 According to the author,


In the last 13 years, major pertussis epidemics have occurred in the United States, and numerous studies have shown the deficiencies of DTaP vaccines, including the small number of antigens that the vaccines contain and the type of cellular immune response that they elicit. The type of cellular response – a predominantly T2 response – results in less efficacy and shorter duration of protection. Because of the small number of antigens (3-5 in DTaP vaccines vs >3000 in DTwP vaccines), linked-epitope suppression occurs. Because of linked-epitope suppression, all children who were primed by DTaP vaccines will be more susceptible to pertussis throughout their lifetimes, and there is no easy way to decrease this increased lifetime susceptibility. (Cherry, 2019)5


Improving the Efficacy of Vaccines


Beyond the discussion of optimization, I have a subset of parents who come to my office having made an informed choice to vaccinate but who will not waver from their decision to follow a delayed schedule. Their choice is based on infant immunity, specifically their understanding and capability of seroconversion in an infant. In an article published in the Journal of Pediatrics, Dr Paul Offit, MD, a pediatrician and vaccinologist, addresses parents’ concerns over their infants receiving multiple vaccines at once.6 One of the papers he cites is a 2001 article by Claire-Anne Siegrist, in the journal Vaccine, which addresses infant immunology.7 Siegrist points out that although vaccines can lead to effective immunological priming, low antibody responses – as a result of an immature Th1 response under 1 year of age – causes most vaccinated infants to have low or undetectable antibody concentrations as early as 6-9 months after completing the primary immunization series; as a result, they require a booster dose during the baby’s second year of life.7 She also suggests that immunizing before 1 year of age may be linked to waning immunity against measles; this appeared to be borne out in both West Africa and Finland among children immunized at a young age.


What I found especially interesting in Siegrist’s article was the finding of a slightly decreased disease prevalence when the third immunization dose is delayed in the infant’s second year of life. This was noted in a large Swedish study, in which the DTaP pertussis vaccine was given on a schedule of 3-5-12 months rather than 2-4-6 months.8 The result was a lower overall risk of pertussis when the third dose was delayed to 12 months. In a similar study, higher antibody production occurred when the hepatitis B vaccine was given at 0, 1, and 6 months, as compared to 0, 1, and 2 months of age.9 These differences reflect the importance of intervals, in terms of the maturation of antigen-specific B-cells after immunization.


Another critical adjustment I make when it comes to vaccination is advising parents to refrain from the use of acetaminophen pre- or post-vaccination. According to the authors of an article10 published in the journal Human Vaccines & Immunotherapeutics,


Antipyretic analgesics are widely used around the time of vaccination to ameliorate fever and pain. They have been shown to decrease vaccine reactogenicity, and until recently have not been associated with decreased vaccine immunogenicity. However, an open label, randomized study by Prymula et al. demonstrated that while acetaminophen (paracetamol) prophylaxis significantly reduced fever following routine childhood immunization, it simultaneously blunted the immune response to several vaccine antigens. (Saleh et al, 2016)10


Because of these findings, I strongly advise parents to avoid the use of acetaminophen before and, if possible, after administration of the vaccine, all while discussing the use of other antipyretic agents if deemed necessary.


Conclusion


Beyond the vaccine discussion, my role as a naturopathic doctor is to help support children when they are sick. What else can parents do to prevent their children from getting sick? Or, what can they do if their child does get sick with a non-preventable vaccine infection? As naturopathic doctors or those who practice integrative or functional medicine, we have other tools at our disposal to help sick children and adults regardless of their vaccine status.


Overall, the climate surrounding vaccine discussions between you and your patients should be amicable. There is a safe, proactive, and healthy approach to vaccinating that does not have to be fueled by fear.

Originally published in Naturopathic Doctor News & Reviews on August 12, 2019.


References:

  1. College of Naturopathic Physicians of British Columbia. Immunization: Standards and Guidelines. Updated May 25, 2018. CBPBC Website. http://www.cnpbc.bc.ca/wp-content/uploads/2018-05-25-Immunization-Standard1.pdf. Accessed April 15, 2019.
  2. BC Centre for Disease Control. Measles information for British Columbians. March 19, 2019. BCCDA Web site. http://www.bccdc.ca/about/news-stories/stories/measles-information-for-british-columbians. Accessed April 15, 2019.
  3. Derban A, Harper J, Jiwa S, et al. Immunization Communication Tool for Immunizers. 2013. British Columbia Immunization Committee Professional Education Working Group. Available at: https://tinyurl.com/y67o4cbh. Accessed April 15, 2019.
  4. Centers for Disease Control and Prevention. 2018 Provisional Pertussis Surveillance Report. January 2019. CDC Web site. https://www.cdc.gov/pertussis/downloads/pertuss-surv-report-2018-508.pdf. Accessed April 15, 2019.
  5. Cherry JD. The 112-Year Odyssey of Pertussis and Pertussis Vaccines—Mistakes Made and Implications for the Future. J Pediatric Infect Dis Soc. 2019 Feb 22. pii: piz005. doi: 10.1093/jpids/piz005. [Epub ahead of print]
  6. Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109(1):124-129.
  7. Siegrist CA. Neonatal and early life vaccinology. Vaccine. 2001;19(25-26):3331-3346.
  8. Olin P, Hallander HO, Gustafsson L, et al. Measuring protection; a case study of pertussis vaccines–Swedish Trial II: secondary non-randomized comparisons between two schedules of infant vaccination. Dev Biol Stand. 1998;95:211-220.
  9. Goldfarb J, Baley J, Medendorp SV, et al. Comparative study of the immunogenicity and safety of two dosing schedules of Engerix-B hepatitis B vaccine in neonates. Pediatr Infect Dis J. 1994;13(1):18-22.
  10. Saleh E, Moody MA, Walter EB. Effect of antipyretic analgesics on immune responses to vaccination. Hum Vaccin Immunother. 2016;12(9):2391-2402.