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A little brown envelope arrived by regular post to the offices of a great many doctors in the first week of the New Year. This seems to be the normal route for communicating great advents in social medicine. It was filled to the brim with confusion. Contained within it was a brand new immunization schedule dotted with rules and exceptions. In case you haven't heard, the good news is that the Provincial Liberal government has decided to fund three additional vaccines for infants and young people. The ministry of health did their part by laminating a maze of rules and date exemptions to ensure that siblings will all receive different shots at different times. Despite holding the envelope up to light and shaking it twice, it only contained paper and nothing else. What did I expect? A simplified computer program would be nice, some vaccines or even a brochure to give to patients would be nice. My colleagues and I have once again been carefully maneuvered into the position where countless extra hours and days will now be required to explain, procure, transport, prepare, record, book, order, follow-up, weigh, sterilize, and then explain some more as to what this all means.
I am completely in favor of providing vaccinations to our children. Despite bacterial pneumococcal serotypes and meningococcal group C bacteria being less common causes of meningitis, if you can prevent it, then why not? The vaccines are safe for the most part. There is plenty of data to substantiate this. Data is sorely lacking as to what can be expected when vaccines from different manufacturers are mixed. Historically, when law suits arose around reactions resulting from multiple administrations, vaccine makers generally blamed each other first, and then jointly put their cross-sights on the physician. The only product insert that assured me that the vaccine could be given with competitors' products without severe adversities came from the same company that advised physicians that Vioxx was safe for heart patients. It seems that the loudest assurances that mixing vaccines is safe come from people who don't administer them for a living, get paid to say it, or stand to make a profit from vaccine sales. Historically, pressures were brought on manufactures and researchers to develop combined products, and they did. With multi-million dollar contracts at stake, I would like to see pressures exerted on manufacturers to produce multi-strain single shot vaccines. The current shots given to infants consist of series of vaccines containing 5 in 1 and 3 in 1 antigens. To follow the new guidelines with existing products introduces the prospect of a newborn receiving up to 22 needles in as many months. This is a concern to any parent. If your child is healthy and born in 2005, he or she will be eligible to receive 14 immunizations over the next two years. This will result in protection against 12 disease entities. Most shots have to be given multiple times. In some cases, such as MMR, this is simply because a low "take" occurs with only one shot. In other cases, a booster dose is required. At the other end of the spectrum, it seems that most school age youngsters in this province will at best qualify for only one shot under the guidelines. I presume that will save money.
The first inkling that this confusion was not restricted to my mind alone came on the evening of the worst snow storm in January. I drove through blinding snow to attend a seminar at the convention center, only to astoundingly discover that over 200 other doctors braved the elements as well in hopes of procuring some answers for their patients. The buzz throughout the room clearly demonstrated the confusion and uncomfortable feelings associated with the new policies. Cleverly disguised as an immunization update session, it quickly became apparent that it was another hard sell by a vaccine producer to promote the ordering of their product. The speakers were even "surprised" that the health authorities did not attend to explain the inconsistencies. In the aftermath, it turned out that health officials were never invited in the first place. But health officials have also failed to recognize that there is even a plate to step up to!
Some of the inconsistencies that I sincerely hope get resolved in the near future are as follows. The pneumococcal vaccine is funded for the full 4-dose infant schedule, yet the meningococcal vaccine is not funded until 12 months of age, contrary to instructions on the inside cover. Furthermore, if this window is missed, then the child has to wait for 11 more years for official funding. In the meantime, various health departments are contemplating conducting their own separate campaigns of going into some schools to administer one of the vaccines, a move that will continue to confuse record keeping. The tables imply that doctors give multiple shots, yet the fine print warns against cross-reactions. If the first visit to your doctor takes place at 12 months of age, the guidelines suggest administering 5 shots at once, keeping in mind that most kids only have 4 injection sites (2 arms and 2 legs). Vaccine distribution seems to be in small amounts which require unmanageable amounts of unfunded administrative time. Vaccine record cards and side effect profiles are not available. Some other vaccines, like rabies shots for high risk veterinarian workers, are also not yet available.
What this all demonstrates is that an idea that starts out as a wonderful altruistic concept around the caucus table, goes through so many levels of government, committees and revisions, all with associated costs, and ends up as a loosely organized concept, confusing front line physicians. For the time being, I am giving one shot at a time, carefully watching for side effects and then calculating the next move one patient at a time. Parents still have the option of buying the various vaccines and having them administered according to manufacturers' guidelines. I would suggest that for the time being, parents keep careful track of which vaccine is given, the manufacturer, date given, by whom, the lot number, expiry date, the amount given and the site where it is administered. As always, I am certain that with time front-line physicians will find the ingenuity to transform guidelines authored by non-practicing academics into a workable system, hopefully. What is sad is how resistant a multi-layered system can be in seeking feedback from the point of entry. What is even sadder is that these issues land squarely on the shoulders of physicians to explain to parents why kids from the same family have different shots at different times from different providers. It's time to play some hockey before my mind bursts. See you in the slot!
