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Editorial AUGUST
2009
Vaccination: Old Tricks and New Paradigms
Lee P. Shulman, MD
For those of us who chose to go into ObGyn and women’s health, the world
of vaccines was a topic that most of us, until recently, viewed only at a
great distance from our professional rearview mirrors. Yes, we had the occasional
patient who needed a tetanus booster or was traveling overseas or, most commonly,
was asking for a flu shot. But our front office staff had the phone number
of the travel clinic or family medicine practice or internist who provided
vaccinations. This was not a part of our practice and was something in which
we had little to no professional (or economic) interest.
Two unrelated events have changed everything when it comes to vaccinations
and
ObGyns. First, the past decade has witnessed an ongoing debate about the actual
role of the ObGyn in the health care system. Are we specialists or primary
care providers? While I won’t
be addressing that issue in this column, it is clear that many ObGyns function
as primary care providers in their communities. Second, the development and
successful marketing of the quadrivalent human papillomavirus (HPV) vaccine
dragged all of us, willing and unwilling, primary care provider or specialist,
into the vaccination world. I believe that the integration of the HPV vaccine
into women’s health care (and hopefully soon into universal health care)
is one of the great public health advancements for women in the past several
decades.
However, incorporating the HPV vaccine into women’s health care is not
without challenges. While we well understand the issues surrounding HPV and
cervical dysplasia and malignancy, we have had scant experience with vaccination
office protocols. On the other hand, our colleagues in pediatrics, family
medicine, and internal medicine understand how to integrate vaccines into
medical practice, but they may not have the professional experience or comfort
with dealing with sexually transmitted infections. These challenges are being
overcome with the many available educational programs for professionals; combined
with patient education programs, these efforts will help to make the HPV vaccine
a great clinical success.
It turns out the HPV vaccine is just the tip of the immunization iceberg.
From therapeutic vaccines in oncology to an expanding array of vaccines for
adult-onset diseases to the recognition of the value of vaccinating all pregnant
women against influenza,1 it is clear that vaccination is now a critical part
of comprehensive ObGyn care.
While medical professionals are well aware of the benefits of vaccines, many
health care consumers still have safety concerns, especially in pregnancy.
These concerns are exacerbated by unscientific reports in the lay media and
high-profile celebrity opinions such as those of Jenny McCarthy. However,
an impressive body of literature exists that shows that vaccines are safe
and effective and are a vital part of preventive medicine for children and
adults.
When evaluating vaccine safety data, it is important to recognize the difference
between “association” and “causation.” Lay people
usually blur these concepts, but the differences are considerable and clinically
relevant regarding rare adverse events. Adverse events do occur among people
getting vaccinated, from death
to Guillain-Barré syndrome to a variety of less severe conditions,
but it is clear that these occurrences are varied and disparate and not linked
to any particular vaccination. To reasonably
avoid these sequelae, there are many information sources that provide guidelines
on when to offer particular vaccines to specific patients.
Regarding practice management: We already have a way to remind our patients
to return for a DMPA or HPV shot, so we now should be able to include the
other injection protocols for our adult patients. And finally, adding vaccinations
will not be an economic burden to our practices, as insurance companies recognize
the value of vaccination in preventing disease and usually cover these services.
Vaccines are not just for kids anymore, and we need to recognize their value
in the care of
the reproductive, pregnant, and menopausal woman. We need to get on board
the vaccine train, as it is carrying critical components for the future success
of preventive medicine that our patients demand and that we need to provide
if we are to remain a relevant part of their health care.
back to top
Lee P. Shulman, MD, Editorial Board
REFERENCE
- Zaman K, Roy E, Arifeen SE, et al.
Effectiveness of maternal influenza immunization in mothers
and infants. N Engl J Med. 2008; 359(15):1555-1564.
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