Measles outbreaks around the world are becoming commonplace. Young physicians are seeing the disease for the first time in their careers. Public health officials are managing outbreaks that haven’t been seen for decades. There is definitely a palpable fear mounting all over the world for what our immediate future holds in terms of the spread of vaccine-preventable infectious diseases.
There are a number of theories for why measles is making such a comeback, and by far the most plausible explanation is that too many parents are choosing, despite consensus medical recommendations, to not immunize their children. As the number of unvaccinated children rises, so too will the rates of measles along with its hideous complications: pneumonia, blindness, meningitis, encephalitis, and death.
Yesterday, a colleague of mine asked me what our office policy is regarding managing patients with suspected measles infections in the clinic. The honest answer is that we don’t have one. Until recently, there hasn’t really been a need for such a policy. But, as measles rates rise in North American big cities, so too does the chance that someone contagious will walk through my clinic doors. The reality is that the moment someone with measles walks into a building, everyone in that building has been potentially exposed. What if that building was a medical building? What if there was a pediatrics practice in that building with a waiting room crammed full of babies too young to get immunized? It’s a horrifying thought.
Physicians are beginning to plan for this in the hopes of mitigating this risk. Many clinics have implemented the “fire all vaccine-refusing patients” policy. I have previously shared my thoughts about this. But how does the situation change when there is a measles outbreak in my city? How would I feel about a non-immunized patient coming to my practice during a local measles outbreak? In the absence of an outbreak, the risk of that patient bringing measles into the office is trivial. But when measles is spreading through the community, that risk increases dramatically. One becomes contagious before knowing that one has measles.
On a regular basis, there are patients with cancer, patients on chemo, patients with immune deficiency, and babies too young to receive their measles vaccine sitting in my waiting room. Providing a venue for the spread of measles (and other vaccine-preventable infectious diseases) to these patients is not only unfair to them, but a liability for me. It is my responsibility to keep my patients safe.
On the other hand, an unimmunized child (whether because she is not able to receive vaccines or her parents made the decision against immunization) has the right to receive medical care.
I decided to share this dilemma with my social media community as a Twitter/Facebook Poll.
I asked:
7 folks responded with a simple “Yes”.
Below is a sample of other insightful responses I received:
“So then how would unvaccinated patients ever get a vaccine or hear more about it if they aren’t allowed to your clinic?”
“Yes. They should pay for a house call.”
“I respect parents’ choices, but I wouldn’t take my fully vaccinated child to you if you didn’t. Certainly not a newborn.”
“Absolutely justified. They must understand it’s for their PROTECTION. They chose not to protect themselves, you do it for them.”
“My gut reaction is yes…but how do you turn away sick kids? not an easy question for doctors.”
“Yikes! Those poor kids still need care but they put your infant patients at risk.”
“Only if it isn’t going to stop them getting access to health care. Up to and including you doing a home visit. Otherwise wouldn’t that be contrary to the Hypocratic Oath?”
“Isolate? Book at end of day after clinic closed?”
“Quarantine them in a separate area. If not you’re punishing the kid for parents poor judgement…”
“A febrile/symptomatic unvaccinated person should not be in the vicinity of other patients. With respiratory virus season still in effect, that’s at least 3-5 feet. For measles (or suspected), it’s airborne precautions. Basic rules of infection control/precautions. Since you’re not able to implement those, you should (and are probably in the medico-legal right to) exclude those patients from your clinic space. Of course, it would be defensible because of it would be based on infection control/public health reasons, and not because of a personal opinion that anti-vax people are negligent.”
“You are entitled to defend the health of all your patients.”
“Wow!!! No! absolutely not!”
“I’m appalled a doctor would be asking such a question.”
“If there are cases of Measles in [town], the children should remain home and that doctors should be coming to their homes to treat them, this way the spread of the virus can be contained”
“Please do. Unless they are coming in to be vaccinated, or they can’t be vaccinated for medical reasons.”
Not unexpectedly, there were opinions from all over the map. What resonated most with me was the notion that as a physician and clinic director, I am responsible for the safety of any/all patients who come to clinic. If the spread of measles becomes a clear and present threat, it is justifiable to take measures that will protect my patients, especially the sickest, youngest, and frailest among them.
I hope to never be faced with this dilemma.
If you have any thoughts, recommendations, or experience making these sorts of challenging ethical decisions, please share your thoughts below in the comments section.
My daughter contracted varicella from her un-vaccinated cousin and suffered a life-threatening seizure. She had had her first vaccine, but not the second.
I hope you are taking seriously the threat un-vaccinated children pose to your other patients.
Our clinic (for university staff and students) had to prepare this fall for the possibility of measles, when there was an outbreak in southern Alberta – didn’t have to really test out our preparations though. Some differences between provinces – MMR vaccinations (and other routine vaccinations) are done by public health in Alberta, not by individual physicians, so we wouldn’t have been encountering any potential overlap between those wanting to be vaccinated and those potentially with the illness. Alberta Health Services had instituted a special clinic outside the Lethbridge hospital emergency department, and also did a lot of publicity of “if you think you might have measles, do NOT go to your physician’s office but instead call HealthLink or go to the special measles assessment centre” (by calling HealthLink, they had special assessment teams to go to people’s homes apparently to assess if needed). We had expected that if measles did seem to move north to Edmonton, that likely a similar recommendation (don’t go to the doctor, call us first) would have been enacted here as well by AHS. We did put a triage system in place, with notices at the front door “if you have these symptoms, immediately tell the front desk” and those patients would have been placed in our “quarantine” area for further assessment so as to not sit in the waiting room and potentially infect others. Like I said, we didn’t really have to test it out, but we’ve done the preparation work if there is another outbreak here.
I am sorry Dr Flanders, but I do not agree with your view on this one. I come from Europe and in most countries in Europe is advisable for a kid to have the “childhood diseases” as a child. There is a reason they called childhood diseases and I wish you would explain to everyone what are the risks of having a “childhood disease” as an adult. Also, I would be very interested in finding out how many of the vax kids develop childhood diseases even if completely vaccinated (I know 2 situations only around my friends and one of them is a 19 year old who was up to that with his MMR), what is the percentage of developing an additional disease while on measles as a healthy child and what is the percentage of developing same diseases as a healthy young adult or even elderly.As a child,I / my friends were exposed to these childhood diseases.There was a time when is was considered normal to have one and for a woman to develop natural long lasting antibodies to these “childhood diseases” was also something one wanted.As a child, even if I have 100% exposure in the world I only developed 1 of the diseases and I am now immune to it.My antibody check prove it almost 30 years later. I do agree with the proposal that the pediatrician can help the client as home if suspected by a childhood disease.It seems the fair solution to everyone and in these situations it’s advisable to keep the contact at minimum.
I do believe in informed choices and I do believe that vaccination can have a tremendous help in eradicating some terrible diseases (polio, variola, tetanus, I hope soon for a vaccine against the most cruel forms of bacterial meningitis).However I also believe that there are some diseases that are worth exposing to as a child.
I can’t help but wonder: if vaccinating us over and over and over every 5-10 years against anything that is considered “reasonably preventable” is the solution?What if we would discover a vaccine against all of the diseases would that be a solution for us to live in a virus free world or would we be even sicker than before?
Cristina, I respectfully disagree with you.
I heard a CBC radio interview this morning talking about new measles cases in Southern Ontario and it reminded me that I had thoughts on this post and should comment. Dr. Flanders, I know that you lead a very innovative practice when it comes to technology, and I would encourage that kind of thinking in this instance as well. I wonder if you could train the desk staff to ask screening questions for measles or any other communicable, life-threatening outbreaks as they should come up? If a case is suspected, the doctor could then Skype the patient for preliminary diagnosis and then follow up with a house call if necessary? Everyone would get treatment this way while still keeping patients like new babies or those with compromised immune systems safer. I don’t know if this is the most practical idea, but I know you’ll come to a solution using the kind of leading-edge creativity and care your patients have come to expect.