Pertussis Infection in a Naturopathic Primary Care Setting: Reflection on a Case

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Luciano Garofalo, ND^1,2; Joshua Corn, ND, MS¹; Meghan Sperandeo, ND¹

Perm J 2020;24:20.065

https://doi.org/10.7812/TPP/20.065

E-pub: 09/16/2020

ABSTRACT

Introduction: Pertussis is a vaccine-preventable disease that has made a global resurgence in the 21st century. Vaccine hesitancy remains a persistent barrier to achieving protective vaccination rates. Vaccine-hesitant individuals may be more likely to seek counsel with a naturopathic doctor. Seven more state legislatures have voted to license and/or regulate naturopathic doctors in the last decade, illustrating the growing popularity of naturopathic medicine in the present health care landscape. Still, the growth of naturopathic medicine, and its potential relationship to vaccine hesitancy, is worrisome. Naturopathic doctors can be advocates for immunization to vaccine-hesitant individuals, but ambivalence toward vaccines within the profession remains a public health concern.

Case Presentation: We report cases of pertussis in a family treated in a naturopathic primary care clinic, where naturopathic doctors served as vaccine advocates to a vaccine-hesitant family.

Discussion: Continued collaboration with public health programs and conventional clinicians is necessary to improve medical science training and vaccine advocacy in the field of naturopathic medicine.

INTRODUCTION

Pertussis is a vaccine-preventable disease that has made a global resurgence in the 21st century. There are several factors acting simultaneously that lead to this resurgence.¹ One factor may be the Bordetella pertussis bacterium’s ability to change its antigenic isoform and avoid vaccine-conferred immunity, much in the way that bacteria develop antibiotic resistance.² The acellular pertussis vaccine is specific to a limited number of pertussis antigens, and immunity conferred by this vaccine wanes quicker than is needed for pertussis control across the population.³ Until more effective pertussis vaccines are developed, high immunization rates are critical to protect vulnerable individuals. Undervaccination is associated with increased odds of pertussis infection in children aged 3 to 36 months in a dose-dependent relationship; the odds of pertussis infection increase with each dose of the vaccine that is skipped.⁴

Vaccine hesitancy, defined by the World Health Organization as the “delay in acceptance or refusal of vaccines despite availability of vaccination services,” remains a persistent barrier to achieving protective vaccination rates. Vaccine hesitancy tends to develop in population clusters, leaving these areas more vulnerable to disease outbreaks.⁵ Vaccine hesitancy has also been shown to persist despite outbreaks of vaccine-preventable disease.⁶

Attitudes toward vaccination in the field of naturopathic medicine have historically been mixed, with evidence of professional enculturation driving vaccine hesitancy among naturopathic medical students.^7-9 Research suggests an association between vaccine-hesitant parents and naturopathic care.¹⁰ Survey data from Australia and Canada have demonstrated that parents who trust complementary and integrative health care professionals as a source of information on vaccines are more likely to have undervaccinated children.^10-12 Another study investigating use of complementary and integrative health care professionals in Washington state found that compared with the general population, undervaccinated children are more likely to use NDs, and children who visited NDs had higher rates of vaccine-preventable illness.¹³ Licensure and scope of practice for naturopathic doctors (NDs) varies by region, so the limited available data may not be representative. Additionally, there is a growing call within the field for all naturopathic professional associations and schools to endorse the Centers for Disease Control and Prevention (CDC) immunization schedule.^14,15 Disease prevention is one of the central principles of naturopathic medicine and is consistent with the practice of vaccination.

The following case illustrates the role that NDs can serve as vaccine advocates to vaccine-hesitant families. The case comes from an academic health center where naturopathic medical student interns manage patients under the supervision of an attending physician. The clinics offer primary care services to predominately uninsured patients or Medicaid recipients, including the full regular (nontravel) CDC schedule of immunizations for children and adults as part of the federal Vaccines for Children Program.

CASE PRESENTATION

Presenting Concerns

A mother and 2 of her female children, aged 8 and 10 years, presented to the naturopathic primary care clinic complaining of a cough of 2 weeks’ duration. Two of their siblings (aged 3 and 5 years) had laboratory-confirmed pertussis diagnosed by an urgent care clinic 6 weeks earlier, after exposure to a confirmed case of pertussis at their church daycare. Both of these siblings had been treated with antibiotics by the urgent care clinic. The oldest child was vaccinated according to the CDC schedule until 15 months of age, at which time the parents decided to avoid all future immunizations, citing religious reasons. The other children were completely unvaccinated.

The 2 older children’s cough was worse at night and was described as paroxysmal and spasmodic, causing episodes of apnea followed by inspiratory whooping and vomiting. The mother produced a list of natural remedies that she had been using to treat her children without recommendation or supervision from a clinician. The list consisted of homeopathic remedies, vitamin C, vitamin D, and more than 20 different botanicals (eg, eucalyptus, oregano, lavender, thyme, licorice, frankincense) prepared as teas, syrups, steam inhalations, or salves.

The children were pleasant and afebrile. Oxygen saturation, heart rate, and respiratory rate were all within normal limits. They exhibited a mild cough but were otherwise breathing comfortably in the office. They both had anterior cervical lymphadenopathy. Their lungs were clear on auscultation. The remaining physical examination findings were unremarkable.

Therapeutic Intervention and Treatment

Based on the strong epidemiologic link and characteristic symptoms,¹⁶ we empirically diagnosed pertussis and notified the state Department of Public Health. A 5-day course of azithromycin was prescribed for both children and the mother, following the CDC and standard-of-care recommendations to administer antibiotics to patients within 3 weeks of exposure or within 3 weeks of symptom onset.^17-19 Although antibiotics may not affect the course of illness, administration of antibiotics is recommended to reduce spread to individuals at risk of development of severe pertussis infection.^17,18 We instructed them to discontinue using all the natural therapies described earlier, with the exceptions of honey orally and steam inhalation for symptomatic relief of cough, and oral probiotics to prevent antibiotic-associated gastrointestinal tract issues.

We discussed vaccine avoidance with the mother. As motivation to encourage vaccination, we provided her with information about the benefits of the CDC catch-up schedule for pertussis immunization, as well as the risks associated with multiple antibiotic courses in childhood.²⁰ We strongly recommended that the children be brought up-to-date with vaccinations but offered reassurance that the children would continue to receive care regardless of the parents’ decision.

Follow-up and Outcomes

Close follow-up was maintained with the family via telephone. All patients recovered fully without complications. A case timeline appears in Table 1. The pediatric patients’ guardian consented to the writing and publication of this case report.

DISCUSSION

Vaccine hesitancy is complex, and each vaccine may be associated with specific parental concerns. For example, parents who delay or refuse the pertussis vaccine for their child are more likely to cite reasons such as pertussis not being a serious or common disease, whereas the measles-mumps-rubella (MMR) vaccine is more associated with the fear of it causing autism.²¹ The limited studies on interventions to address vaccine hesitancy have revealed that there is no one-size-fits-all approach. Provaccine messaging alone is ineffective and may even be counterproductive.^10,22 In the effort of shared decision making, clinicians should practice motivational interviewing with vaccine-hesitant parents to reveal their unique beliefs and concerns about vaccination.²³ Any subsequent education that is needed should be specific to each vaccine in question, delivered without judgment, and rooted in scientific evidence.

Naturopathic doctors are trained to value the unique situation of each patient and hold patient education (docere) as a core principle, in addition to prevention. For these reasons, NDs may be uniquely positioned as immunization advocates for vaccine-hesitant individuals. Because NDs are labeled as complementary and alternative health care professionals and have a philosophical affinity for nonpharmacologic therapies, they may be viewed as more trustworthy by individuals who distrust biomedical institutions. Also, NDs tend to spend more time with patients than other doctors, and time is necessary to field concerns and questions about immunization.²⁴ In this case, the family preferred naturopathic primary care because of a value system that prioritized natural remedies over pharmaceuticals, as is often the case for patients who use complementary and integrative health care professionals. Furthermore, some families avoid conventional medicine because of conflict with clinicians over treatment preferences and belief systems around health care. Although the American Academy of Pediatrics advises against barring care to children whose parents refuse immunizations, many pediatric clinics still adopt this policy, and it is a subject of ongoing debate.²⁵ Naturopathic doctors often fill the role of a safety net for such patients who would otherwise not return for follow-up, and they provide culturally relevant and patient-centered care. Persistent counseling from vaccine-educated NDs might be a key component to eventual vaccine uptake in even the most skeptical patients.

In addition to nonpharmacologic therapies, naturopathic medical students are currently taught standard-of-care medicine, including the CDC immunization schedule and education of vaccine-hesitant individuals.²⁶ This innovation in naturopathic education is both in response to and in preparation for the expanded role of NDs in some states. However, the growth of vaccine hesitancy in the US, and its potential relationship with naturopathic medicine, is worrisome. In addition to professional enculturation, nonscientific immunologic beliefs may engender vaccine hesitancy and are reflected in the real-world practice of some licensed NDs.^27,28 Such beliefs are likely multifactorial and could stem from idealistic interpretations of naturopathic philosophy. One example is the oversimplified position that synthetic drugs impede the body’s natural healing process.²⁹ Conversely, other NDs and naturopathic organizations profess support for the practice of immunization and the CDC schedule.^14,30 We argue that a cohesive endorsement of vaccine science across all naturopathic professional and educational organizations is necessary to edify a new generation of NDs who support the practice of immunization.

Seven state legislatures have passed bills in the last decade to license and/or regulate NDs, with the most recent being New Mexico in 2019, where NDs are now eligible to provide primary care.³¹ This growth would not have been possible without endorsements from stakeholders in conventional medicine and public health. In the treatment of patients who are more likely to be vaccine hesitant, it is neither safe nor sustainable for NDs to remain ambivalent about the value of immunization as a routine public health practice. Stronger relationships between NDs, conventional clinicians, and public health programs are needed to increase vaccine adherence in patients who use naturopathic medicine.

CONCLUSION

Pertussis control requires higher immunization rates in the absence of a more effective vaccine. Naturopathic doctors can be advocates for immunization to vaccine-hesitant individuals. Support for immunization among NDs is growing, but ambivalence toward immunization remains a public health concern. Continued collaboration with public health programs and conventional clinicians is necessary to improve medical science training and vaccine advocacy in the field of naturopathic medicine.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copyedit.

Author Affiliations

¹ National University of Natural Medicine, Portland, OR
² University of Washington, Seattle, WA

Corresponding Author

Luciano Garofalo ()

Author Contributions

Luciano Garofalo was the student intern assigned to the case, conceptualized the thesis, drafted the initial manuscript, and revised the manuscript. Joshua Corn, ND, MS, was the resident assigned to the case and reviewed and revised the manuscript. Meghan Sperandeo, ND, was the attending physician on the case and reviewed and revised the manuscript. All authors have given final approval to the manuscript.

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Keywords: immunization, naturopathic, primary care, vaccine hesitancy, vaccines