As a Canadian board certified Naturopathic Doctor  (ND) located in British Columbia, part of my scope of practice includes administration of vaccines. As of 2019, I am one of the few (though many more to come) naturopathic doctors in British Columbia (BC) who has 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

As an ND offering vaccines, does it look different for patients to vaccinate with me verses their public health nurse? Most likely. Why? Simply because of time. I have the privilege of offering 30min to 60min consultations for patients to ask the questions they want so they can achieve common ground around the topic of vaccines.

My approach to vaccines is no different then any other intervention I offer in my office. The conversations I have with my patients encompass unbiased, evidenced based research along side a respectful space to ask questions and share concerns.  At the end of the day, my patients make the ultimate decision if they vaccinate or not. They bear the full responsibility of their decision and they walk out of my office understanding this.

Vaccinating in Canada

I have noticed over the past decade, the culture around vaccination has changed and families are finding it difficult to simply have a rational, transparent, conversation that is not fuelled with anger or fear.  As a healthcare provider who offers vaccines, I am striving to become an expert because that is the job of the physician – you offer interventions to patients because you understand the breadth of what you are doing. If you do not, then you refer to someone who does.

My clinical experience and reading on several public forums, has proven to me how apparent many are avoiding the conversation around vaccination simply because of how uncomfortable it is. One of the most common things I hear from my patients is “I have a few questions and I have not found any health care practitioner will answer them” or “I feel very uncomfortable when I bring up any questions around vaccines with my doctor.” The moment someone feels uncomfortable, shamed or belittled is moment the movement of hesitancy and avoidance is born.

My mission then by offering vaccines is not only to educate patients around vaccines and infections we vaccinate against but to also create a psychologically safe place for people to have a conversation, which should already be in place.  However, due to the feedback by my patients in Canada and internationally, a psychologically safe place is not what they experience.

Here in Canada, vaccines are a choice. In British Columbia, the BCCDC has stated that vaccination is the right of the individual. During my training to obtain my immunization certificate, 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.” ²

Vaccine side effects and reporting

During my discussion around vaccines with parents, the topic of side effects typically comes up.  What I tell them is there is potential to have a side effect to any intervention we use, be it a pharmaceutical prescription, herbal medicine to even supplements.  Commonly the side effects are mild and short-lived, but in rare cases more severe adverse events may occur. In Canada there is an Active Surveillance and Passive Surveillance of vaccine adverse events. IMPACT, Immunization Monitoring Program ACTive, is a pediatric hospital-based national active surveillance network for adverse events in children following immunization to vaccine failures. They work to achieve a nation wide vaccine safety monitoring and disease reporting. CAEFISS, Canadian Adverse Events Following Immunization Surveillance System, is a voluntary reporting system in which AEFI reports collected by provincial and or/territorial public health authorities. 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  Reporting of vaccine adverse events looks different in each state, province and country and it is up to you as the health care provider to understand what this entails. 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.

Tylenol

Another critical adjustment I make when it comes to vaccination is advising parents to refrain from the use of acetaminophen before and after vaccination. According to the authors of an article⁴ 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)⁴

Because of this, I strongly advise parents to avoid the use of acetaminophen along side Tylenol all together all while discussing the use of other antipyretic agents if deemed necessary.

Tdap in Pregnancy and long term vaccine efficacy

Through my experience, I see a missing piece to vaccination– how to optimize vaccination. My career working with vaccines started overseas where a select amount of vaccines are mandated. As a result, I found myself working with pregnant mothers and parents on how we could potentially optimize efficacy of the vaccine and improve immune response. I have had several pregnant patients inquire about vaccinating when they are pregnant. Pregnant mothers are offered the flu vaccine in first trimester or more so at the end of October along with the Tdap vaccine. The purpose of the Tdap vaccine is for the mother to create antibodies to pertussis (whooping cough) so the baby will be protected from birth until their first infant vaccines. What the CDC says is as found on their website:  

Whooping cough, known as pertussis, can be serious for anyone, but for a newborn, it can be life-threatening.

• About 7 in 10 deaths from whooping cough are among babies younger than 2 months old. These babies are too young to be protected by their own vaccination. The younger the baby is when they gets whooping cough, the more likely they will need to be treated in a hospital.
• It may be hard to know if a baby has whooping cough because many babies with this disease don’t cough at all. Instead, it can cause them to stop breathing and turn blue.

When a pregnant woman gets a whooping cough vaccine during pregnancy, her body will create protective antibodies and pass some of them to the baby before birth. These antibodies will provide the baby some short-term, early protection against whooping cough.  CDC recommends getting a whooping cough shot during the 27^th through 36^th week of each pregnancy, preferably during the early part of earlier part of this time period. ⁵

Before I go into speaking about the Tdap in pregnancy, I wanted to point out the infant death toll from pertussis in the USA. The CDC provides an annual Pertussis Surveillance Report which can be used to see cases per state, per age category and per the vaccinated, partially vaccinated and not vaccinated for those that contracted pertussis. In 2019 the number of deaths from pertussis for children under the age of one was 3 for the entire United States. Previous years for infant deaths under one year of age was 3 in 2018, 9 in 2017, and 6 in 2016. The reports date back to 2012 with the highest number being 15 in 2012. ⁶

In terms of the Tdap efficacy, I would like to share information from an article out of the Infectious Diseases Society of America written in 2018 titled: A Randomized Controlled Trial of the Safety and Immunogenicity of Tetanus, Diptheria and Acellular Pertussis Vaccine Immunization During Pregnancy and Subsequent Infant Immune Response⁷. The essence of this paper discusses pregnant women who are vaccinated with either the Tdap vaccine compared to the mothers who were vaccinated with the Td vaccine and how their babies responded to the pertussis portion of their 2,4,6 month infant vaccines. 273 mothers divided into 2 groups received either the Tdap vaccine or Td vaccine. They measured the pertussis antibodies in the umbilical cord and also tested how long the mothers pertussis antibodies lasted during the duration the infants vaccine series. As each infant received their 2, 4, 6 months vaccines, which includes pertussis, their own antibodies were tested at 2 months, 4 months, 6 months and 12 months. What was found, was the mothers who received the Tdap vaccine and had antibodies to pertussis, their babies had a strong level of antibodies received from the mother from birth to 2 months. The interesting finding came when the infants antibodies were tested after they received their vaccines towards pertussis, which showed their antibodies actually started to decline rather than sustain or incline. When compared to the infants who were born to mothers who had received the Td during pregnancy, these infants were successfully making antibodies to their 2,4 and 6 months vaccines, which did not decline but rather showed an incline. The explanation for this unintended consequence of the decline of pertussis antibodies to infants born to the mothers who received Tdap was her own antibodies were blunting the infant from making optimal pertussis antibody levels. It was found that with each vaccine series during the infancy vaccine schedule, the infants pertussis antibodies were declining with each subsequent vaccine, even after receiving the 12 month dose.

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.

References:

1. College of Naturopathic Physicians of British Columbia. Immunization: Standards and Guidelines. Updated May 25, 2018. CBPBC Web site. http://www.cnpbc.bc.ca/wp-content/uploads/2018-05-25-Immunization-Standard1.pdf. Accessed April 5, 2020.
2. http://www.bccdc.ca/health-professionals/education-development/immunization-courses/immunization-competency-course. Accessed April 5th 2020.
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 5, 2020.
4. Saleh E, Moody MA, Walter EB. Effect of antipyretic analgesics on immune responses to vaccination. Hum Vaccin Immunother. 2016;12(9):2391-2402.
5. https://www.cdc.gov/vaccines/pregnancy/vacc-during-after.html
6. 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 5, 2020.
7. A Randomized Controlled Trial of the Safety and Immunogenicity of Tetanus, Diphtheria, and Acellular Pertussis Vaccine Immunization During Pregnancy and Subsequent Infant Immune Response. Clinical Infectious Diseases, Volume 67, Issue 7, 1 October 2018, Pages 1063–1071,https://doi.org/10.1093/cid/ciy244. Accessed April 5, 2020.
8. 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]. Accessed April 5, 2020.
9. BCCDC Immunization Communication Tool for Immunizers ImmunizeBC. http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Immunization/Vaccine%20Safety/BCCDCICT_300315.pdf. Accessed April 5 2020