by Hannelore Sudermann | © Washington State University

Photo by Robert Hubner. Left to right: Haley Tellesbo, Krystina Sturdevant, and Shelby Wahlberg

As the chief of pediatric infectious diseases at the University of Chicago’s Comer Children’s Hospital, Ken Alexander ’82 is no stranger to the measles, pertussis, or chicken pox.

He also works with children with HIV-related illness, pneumonia, and respiratory infections. He and his colleagues identify and treat infections caused by the typical viruses and bacteria as well as the little-known parasites and even fungi.

But when we sit down to visit near his offices on the north end of UC’s campus, Alexander wants to talk about something that isn’t a children’s disease at all.

He leans a little forward, with the gentle manner of, well, a children’s doctor. He answers questions about his childhood in Pullman, growing up watching his father work in the College of Veterinary Medicine, his decision to have his own career in medicine before even enrolling at Washington State University, and his life as a pediatric specialist. But then Alexander steers the conversation to his subject.

This is where it gets—to use a term particular to Alexander’s patients—icky.

Alexander wants to talk about a vaccine for adolescents to prevent human papillomavirus (HPV), a sexually transmitted disease with many serotypes, two strains of which are known to cause cervical cancers. Recently HPV has been connected to a suite of other cancers affecting both women and men. The vaccine was introduced in 2006 and was recommended for girls before they’re sexually active. In 2011, it was recommended for boys as well. The vaccine is widely accepted and encouraged by the Centers for Disease Control and Prevention and our nation’s medical community in general. But since its introduction, the rate of HPV vaccination has leveled off. The general notion of vaccination has been brought into question with the spread of anti-vaccination rhetoric on the Internet.

And then there’s the idea of immunizing children against a sexually transmitted disease that won’t likely be a health issue until they become adults.

“But we should talk about it,” Alexander insists. Vaccines can prevent misery, he says. They can save lives.

The state of Washington

In 2011, Washington’s vaccination rate was dangerously low. According to the CDC, 6.2 percent of children in kindergarten had not been fully immunized. The national average that year was less than 2 percent, and Washington had come in last.

Why was the rate so low? Washington is one of 20 states that allow parents to opt out of vaccination requirements and the rate may reflect a general distrust of government and the medical industry.

But the more members of a community who go unimmunized, the greater the potential for an outbreak. In 2012, Washington led the nation in the worst whooping cough outbreak in 70 years. In 2013, measles made its way to the Puget Sound region.

Since that CDC report of 2011 and the outbreaks, our numbers have greatly improved, says Karen Caines, a pediatric nurse practitioner and assistant professor in the WSU College of Nursing. Now, before parents can opt out, a new law requires them to discuss it with a medical provider.

Some refuse vaccines out of concern for their child’s health and safety, says Caines. They’re worried about side effects, the ingredients, and how effective it will be. And they may be misinformed about the danger of vaccinations and the severity of the diseases they’re meant to prevent. “Parents can feel overwhelmed,” says Caines.

Anti-vaccine movements are nothing new. In the 1800s in England and America, anti-vaccination leagues formed to oppose mandatory smallpox vaccination. The 1970s saw opposition to the tetanus, diphtheria, and pertussis vaccine (Tdap). And in the 1990s, the focus turned to the measles, mumps, and rubella vaccine (MMR). A British doctor, who has since been denied the right to practice in England, published a report that MMR vaccine might be linked to autism and bowel disease. Celebrities like Jenny McCarthy went public with their concerns, linking autism and vaccines. And there are many websites devoted to making similar points, notes Caines.

Despite numerous studies, no association has ever been made between autism and vaccines. One need only look at the reduced infection and mortality rates of diseases like measles and whooping cough to see the value of vaccination, says Caines, whose research interest is health literacy related to vaccinations to increase on-time immunization coverage.

For those who are still concerned, more information from their doctors and nurses or some research into how the vaccines are produced may relieve their worries, she says. There are two types of vaccines. The live attenuated vaccine modifies a bacterium or virus in a laboratory, rendering it able to trigger immunity, but not cause illness. Vaccines in this realm include those for measles, mumps, and chicken pox.

Then there are inactivated vaccines, which are created by growing the bacterium or virus and then rendering it inactive with heat or chemicals. These vaccines include polio, hepatitis A, pertussis, and HPV. These vaccines always require multiple doses, with the first dose priming the immune system, and the second and/or third dose prompting the protective immune response.

As Caines and I look over copies of the CDC’s Morbidity and Mortality reports on vaccination coverage among children, two nursing students make their way into her WSU Spokane office to talk about a project to help new parents learn more about immunization.

“We like kids. We all want to do pediatrics,” says student Haley Tellesbo. “We tried to think of a problem and who we could talk to.” She and her classmates landed on the notion of immunization. “Vaccines are a key issue in pediatrics,” says Tellesbo. Knowing that Washington had a larger number of parents opting out, the students decided to reach out to families who had refused vaccines. They communicated with a number of people in Washington and Montana willing to talk about why they chose not to vaccinate their children. “For some it was religion, others their individual philosophy,” says Tellesbo.

Some of these families may have made different decisions had they talked about it more with their health care providers, the students note. “Mostly, people were getting their information from family, friends, and providers,” says Krystina Sturdevant. “Friends and family may have the highest impact, but they’re not always reliable.”

In some cases “they thought they were correct, so why even ask,” says Tellesbo. One mother believed the shots triggered allergies in her children. Another was concerned multiple vaccinations at once would be hard on her infant. A few parents said they did not trust the pharmaceutical industry. “And some said they thought the vaccine was more dangerous than the actual disease,” says Tellesbo.

The students decided to focus their project on a large Spokane hospital. They are contacting administrators and doctors, asking them to provide information about vaccines to new parents. And for those families who want to do more research, offer them reliable sources for more information.

“Many parents would like to do some research before they introduce a vaccine,” says Caines. “That’s fine, if they’re going to credible sources.”

It’s not always about choice, says Alexander. Some parents simply lack the resources and access. “They have the desire to do it,” he says. “But they just can’t get it done.”

Who is more robust than an adolescent?

Early-childhood vaccines are just half of the challenge, says Caines. Far less attention is given to the series of shots recommended for pre-teens and teens.

“Around 10, kids get pretty healthy,” says Caines. “It’s pretty exciting.” They don’t get every cold, they grow out of some of their early issues like ear infections, they have strong bones, good metabolisms, and tend to heal quickly.

“Teenagers don’t go to the doctor because they’re healthy,” says Alexander. “But that’s the problem.”

It’s exactly the critical age for a flight of vaccinations: one protecting them from diphtheria, tetanus, and pertussis (Tdap), one for meningitis, and one for HPV. The CDC recommends these vaccines for children aged 11 to 12. “And while all three are included in the Recommended Childhood Immunization Schedule, only the Tdap vaccine is a school immunization requirement,” says Caines. “Providers really need to make the case that all three are needed. And that’s difficult if you’re doing it in a 10-15 minute office visit.” Most of the time, the kids come into the doctor for a sports physical and the provider has to squeeze in a number of other points.

“We take on so much during this visit: sexuality, safety, sports participation, peer issues,” says Caines. “Where does vaccination fit into all the priorities?”

In an exploration of vaccine decision making, Caines recently set up an in-house pilot study with junior and senior nursing students to look at how providing more information might affect the parents’ decision about vaccination. The seniors were lectured on basic safety questions and concerns about vaccination, and then they met up with the juniors who were prepared to ask questions. The result was that the juniors who may or may not have thought vaccination was important had moved toward thinking it was more important as a result of the encounter with the more knowledgeable seniors.

“We’re not talking about arm twisting,” she says. “We want them to give good information and feel comfortable giving that information.”

Nurses can also advocate for vaccinating, sharing their own personal decisions, something Caines advises her students and colleagues to do. “If you vaccinate your child, you should tell your patients.”

“We need to shift immunization best practices,” says Caines. For a long time the discussion between provider and parent was brief and about making sure the parent was aware of the side effects and benefits of the immunization, and staying on schedule. “But we need to have more of a conversation around vaccines. We need to address their safety concerns, explaining how the vaccines are developed and how they are put through rigorous safety tests.

“These types of questions can be answered by nurses if they have the right training,” she says.

Nurses, who provide the immunizations and often spend the most time with patients and parents, “are probably more important advocates in this than doctors,” says Alexander.

The newest vaccine

More than 5 percent of cancers worldwide are caused by persistent infection of human papillomavirus. It affects at least 50 percent of the world population. There are more than 100 types known. Two are linked to cervical cancer. Often people who contract the virus never know they have it, says Alexander. Or if they have symptoms, they often clear up on their own.

With support from the National Institutes of Health, Alexander has researched the development of HPV infections. He has also worked on developing antiviral agents. He has authored and coauthored studies on both the scientific and sociological sides of the virus and vaccination against it. He has served as a paid advisor and consultant for the pharmaceutical company Merck & Co., Inc. He also leads continuing medical education clinics for doctors and nurses on preventing HPV-related disease.

“Part of the problem,” says Alexander, “is that this virus isn’t something that children get.” It’s not like chicken pox or measles, or even meningitis, that you might associate with childhood, he says. It’s something people encounter as adults, after they are sexually active.

The release of the vaccine, one that could prevent cancer, was big news a few years ago, with national impact. A series of three shots could prevent 90 percent of cervical cancers. It made the evening news. But that was eight years ago, when the HPV vaccine was introduced for girls.

Now the virus has not just been linked to cervical cancer, but also anal cancer, and head and neck cancers, says Alexander. Last September the CDC released a list of cancers associated with HPV to include throat, tongue, and tonsils. A third of throat cancers show the presence of the HPV virus. According to the CDC there are about 33,000 cases of HPV-associated cancers each year.

But the number of children receiving the vaccine has not increased. With most other new vaccines, the rates at which people get them increase as much as 10 percent every year. But not this one.

As a graduate student in the College of Nursing at WSU in 2009, Kristi Ridgeway looked at the issues of perception and immunization for her master’s thesis. Ridgeway, now a health care administrator in Oregon, focused on vaccination rates of college-age females, a group for which HPV infection is prevalent due to their sexual activity. At the outset she noted that there hadn’t been much study as to whether this group found the HPV vaccination acceptable. She wanted to look at their personal health beliefs and see if there were changes to be made to encourage more to seek or accept the vaccine.

Ridgeway focused on freshman women. The participants in her study filled out a 54-question anonymous questionnaire. About a third of them had received at least one dose of the vaccine, though only 12 percent had completed the series. About half of the respondents said they thought they were not at risk of getting HPV. Forty-three percent were unsure whether the vaccine would be risky to their health. Many thought they had the ability to prevent HPV infection by other means.

“Marketing of the immunization does not tell females of their susceptibility,” she noted. She, too, drew the conclusion that nurses could play a vital role in helping young women develop a realistic view of the virus and of cervical cancer. The nurses could also encourage them to put a high value on their health and recognize their authority to make their own health decisions.

“There’s a lot of people who are going to say it’s about sex,” says Alexander, who has encountered people who worry the vaccine may trigger an increase in unsafe sexual behaviors or give teenaged girls a notion of becoming sexually active.

“But I think this grossly underestimates the intelligence of women,” says Alexander. “Making the vaccine available won’t affect their sexual behavior.” A recent study published in the journal Pediatrics supports his statement. The study found that of nearly 1,400 girls, those who received the HPV vaccine did not show any increase in sexual activity.

“It’s not about sex, it’s about health,” he says. “We need to take the judgment out of it.

“Let’s take it out of the realm of sexually transmitted infection and put it in line with the normal flora ... like the flu,” he says. “Who wouldn’t want to protect their children from getting sick?”