Just in time for the holidays a reader wrote in with this question:

“My friend...was told by her grandson’s pediatrician that her grandchildren who are vaccinated should never be around any unvaccinated children. Well, the parents of her other grandchildren do not want to vaccinate their small children…As a result there are no more family gathering with all grandchildren. They have to spend holidays on separate days. My question is: Why would the pediatrician say this? If the children who are vaccinated and the children are not showing symptoms what’s the problem?”

This is definitely a sad and tricky situation and one that we should use extreme care when discussing.

One thing I will say is that no matter what one’s choice about vaccinating is, parents believe they are making the choice in the best interest of their child. Of course, I have strong opinions about how important it is, but this discussion is not for the faint of heart.

There are probably some doctors that would tell you it’s no big deal and you shouldn’t worry about it (I would disagree with them). There are other doctors that would say you should never have your child around children who are unvaccinated regardless of your child’s health (I recognize this is not reasonable in many situations).

Here are the questions to consider:

1. How old is the child? The younger the child, the more vulnerable they will be to infection. They cannot receive protection for chicken pox or measles before 1 year. Older children who are fully vaccinated have a significant amount of protection and they likely encounter an unvaccinated child at school every day.
2. Who isn’t vaccinated? This question is about family members which makes transmission of infectious diseases more likely than if you just walked by someone on the street and were not interacting with for longer periods of time.
3. Can you have an open conversation with those involved? The discussion is clearly more complicated than simple medical advice as it broaches on several tricky areas including family dynamics and vaccination.

The easy (get out of having to make a committed answer) is that there is no one answer to the question. The family should talk with their doctor about their specific concerns and make a decision with their counsel.

Should I stop the blog post there? Not so fast.

Instead, I want to give you a framework for having that discussion with your doctor.

What diseases should I be worried about?

I believe that all vaccines are important, period. But there are 3 diseases that jump to the top of my list when considering this issue:

1. Flu

Flu season is predictable in that it comes every single year at roughly the same time. It is unpredictable in that we never know how widespread it will be and how severe the cases will be when it does come around. Flu is particularly dangerous in babies and they cannot be vaccinated until they are 6 months old. Remember that the flu vaccine isn’t perfect, so I’m not saying that everything’s cool if we all have flu vaccines but it would seem logical to get as much protection surrounding the baby as possible.

2. Pertussis

Pertussis, or whooping cough, is still common and is a very serious disease for anyone who gets it. In children, teenagers and adults it tends to cause a very rough and painful cough that lasts for weeks to months. I know of adults who have had broken ribs because the coughing is so hard. The real danger for pertussis comes in small babies (less than 3-4 months). These babies commonly have spells of coughing that cause them to stop breathing; leading to ICU stays for intubation and unfortunately, death. Babies are vaccinated against pertussis at 2, 4 and 6 months which increases the number of children who are protected with each shot but they go on to get another vaccine at 4 and 11 years as well. So, when are they fully protected? It’s impossible to say. In addition, vaccines are not perfect so even vaccinated infants who are exposed could develop pertussis. Pertussis still occurs commonly in the United States and is generally carried by older children and adults who are coughing but do not know that they have pertussis. Just like flu, having the vaccine does not prevent disease 100% and I still feel that we need to do something better with the pertussis vaccine but again, it would seem logical to increase protection as much as possible.

3. Measles

Measles is another disease that still occurs in the United States. In 2014, there was a record number of 667 confirmed measles cases reported to the Center for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases (NCIRD). That’s the highest number of cases since measles elimination was documented in the U.S. in 2000. Measles can cause pneumonia and have a higher risk of hospitalization in children under 5. Children receive their first measles vaccine at 1 year of age, but they have no protection from measles until then.

What criteria should I use for being around others?

1. If your baby is under 6 months, use extreme caution. Many babies do not have full protection until after the 6 months shots. In addition, they cannot receive a flu vaccine until 6 months.
2. If your baby is under 1 year, I would also use caution. Your baby cannot be vaccinated against measles or chicken pox until 1 year.
3. After your child is vaccinated at 4 years, they have much of the protection that they need to protect themselves against the vaccine preventable diseases.
4. Babies or children who may not have a normal immune system-such as those with chronic illness or who were born premature deserve extra caution.
5. Anyone with symptoms of illness, especially fever, cough, congestion or rash, should not be around your baby or child regardless of your contacts’ vaccination status.

Can you get a definitive answer about when your baby can be around unvaccinated children? No, but you at least have some information to make an informed decision.

After you’ve discussed your plan with your pediatrician how do you handle the conversation with friends and family?

Here are some thoughts about some things you might say:

1. Our baby/child doesn’t have protection against many very dangerous diseases and we do not feel comfortable having her around people who could spread them to her.
2. Our baby/child has already been through so much, we can’t risk putting her through another medical problem. Especially something that we could have avoided.​
3. The doctor was emphatic that we cannot be out around anyone (especially someone who is not vaccinated or you could leave that out) until __________. (I’m fine with a family placing the “blame” completely on me.)

That’s the concern of Justin Smith, M.D., a pediatrician at Cook Children’s. The Houston Chronicle reported “the number of children whose parents decline vaccinations for non-medical reasons rose nearly 9 percent last school year.”

Since 2003, Texas has allowed parents to decline state immunization requirements for “reasons of conscience.” At the time, 3,000 kids were listed as exempt. According to the Chronicle, that number has since multiplied to 45,000 last year.

“If you look at the statistics, you see a lot of geographic clusters of people who choose not to vaccinate at all or to under-vaccinate their children,” Dr. Smith said. “I suspect that is true across our area as well, but I also suspect that there is clustering according to other factors as well: socioeconomic status, church/religious affiliation, etc. Populations where there are multiple families who choose not to vaccinate would be particularly susceptible in an outbreak situation. Let’s pray we don’t get there.”

Keeping vaccination rates relatively high (somewhere around 90 percent) actually helps protect all children (vaccinated or not) from diseases, Dr. Smith said. In addition, when outbreaks occur, even children who are vaccinated become at risk for contracting disease due to the number of possible exposures.

Dr. Smith points to an NBC5 report last year on vaccination rates in local school districts that he found not only enlightening, but a bit frightening to him. The news focused on the growing number of vaccine exemptions in three public school districts (Frisco, Plano and Lewisville).

“At first glance it may not seem that concerning. If you look at an individual school or district, the percentage of vaccinated children in those districts is still really high,” Dr. Smith said. “My bigger concern, and what keeps me up at night, is in the schools where unvaccinated children, for some reason, are clustered together.”

In the report, what’s happening in our area includes:

• Thirty schools in the DFW area have vaccination rates below 96 percent.
• Five schools in the DFW area have vaccination rates below 90 percent.
• The highest unvaccinated rate in our area is around 13 percent. The highest in the state is near 50 percent.

Why does it matter?

“If you read the names of the schools, you’ll see a trend,” Dr. Smith said. “They are private schools. They are schools that have a high likelihood of having people go overseas for mission trips or other opportunities. Traveling to countries where diseases are more common increases the likelihood of bringing a disease back to school. Waiting at school are their unvaccinated friends and their vaccinated friends who could even be at risk as the number of cases rise. Outbreaks are possible.”

Do you think this is far-fetched?

Dr. Smith points to the Tarrant County measles outbreak from 2013 that basically had all the characteristics that he’s describing. A large group of unvaccinated people, grouped together based on their faith that contracted measles from a visitor who brought measles into the United States after traveling overseas.

What can you do?

• Get the best start to protection by vaccinating your child.
• Be aware of the vaccination percentages of your child’s school, your church and your social community.
• Be especially cautious when your child’s unvaccinated contacts return from overseas travel. If they are sick, stay away.

About the source

Justin Smith is a pediatrician and the Medical Advisor for Digital Health for Cook Children's in Ft. Worth, Texas. He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. His interest in communications started when he realized that his parents were relying more on the internet for medical information. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” is set to open in Trophy Club in the fall of 2016.

We have said this before (many times), but a new study shows just how true this statement is.

A recent study published in the Journal of the American Medical Association (JAMA) looked at the combined data of 18 published measles studies on several measles and pertussis outbreaks.

Reviewing a total of 1,416 measles cases, 56 percent had no history of measles vaccination. This is way higher than you might expect given that most still choose to have their child vaccinated.

Still the study states that “a substantial proportion of the US measles cases in the era after elimination were intentionally unvaccinated.”

Intentionally unvaccinated?

As a pediatrician this concerns me. As a dad, it terrifies me.

In one outbreak the risk of contracting measles was 35 times more likely when parents had skipped the shots. A child who isn’t vaccinated is much more likely to spread measles than a vaccinated child.

We know that the pertussis vaccine is not working as well as we would like. The protection from the vaccine is falling off quickly. However, this study showed that despite this, vaccine exemptions continue to be a factor in the spread of pertussis outbreaks. Somewhere around 1 out of 3 kids who got pertussis during these outbreaks was unvaccinated.

Why are children not getting the vaccines? Not all studies had the information necessary to say. But, for those that did, most families skipped the vaccines for personal or religious reasons (70 percent for measles, 60-90 percent for pertussis).

This is further proof to something we’ve suspected for some time. Having even small pockets of unvaccinated children increases the risk to the whole community.

Each of these families who chose not to vaccinate gamble on 3 issues:

1.Their child would not be exposed to the disease (banking on herd immunity whether they know it or not).

2.If their child was exposed, that they would not contract the disease.

3.If their child contracted the disease, they would not suffer serious consequences.

These are consequences I’m not willing to gamble on.

In the case of measles, consequences could mean pneumonia, hospitalization and, later in life, neurologic complications.

In the case of pertussis, consequences could mean painful coughing, broken ribs and, in the very young, death.

This is further proof to something we’ve suspected for some time. Having even small pockets of unvaccinated children increases the risk to the whole community.