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

Tweet

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 (lu.garofalo@outlook.com)

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.

References

1.    Lapidot R, Gill CJ. The pertussis resurgence: Putting together the pieces of the puzzle. Trop Dis Travel Med Vaccines. 2016;2(1). doi:10.1186/s40794-016-0043-8.
    2.    Sealey KL, Harris SR, Fry NK, Hurst LD, Gorringe AR, Parkhill J, Preston A. Genomic analysis of isolates from the United Kingdom 2012 pertussis outbreak reveals that vaccine antigen genes are unusually fast evolving. J Infect Dis. 2015;212(2):294-301.
    3.     Klein NP, Bartlett J, Rowhani-Rahbar A, Fireman B, Baxter R. Waning protection after fifth dose of acellular pertussis vaccine in children. N Engl J Med. 2012;367(11):1012-9.
    4.     Glanz JM, Narwaney KJ, Newcomer SR, et al. Association between undervaccination with diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine and risk of pertussis infection in children 3 to 36 months of age. JAMA Pediatr. 2013;167(11):1060-1064. doi:10.1001/jamapediatrics.2013.2353
    5.     Omer SB, Enger KS, Moulton LH, Halsey NA, Stokley S, Salmon DA. Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol 2008;168(12):1389-1396.
    6.     Opel D, Dehart MP, Warren J, Rowhani-Rahbar A. Impact of a Pertussis Epidemic on Infant Vaccination in Washington State. Pediatrics. 2014;134(3):456-464. doi:10.1542/peds.2013-3637
    7.     Busse JW, Wilson K, Campbell JB. Attitudes towards vaccination among chiropractic and naturopathic students. Vaccine. 2008;26(49):6237–6243.
    8.     Wilson K, Mills E, Boon H, Tomlinson G, Ritvo P. A survey of attitudes towards paediatric vaccinations amongst Canadian naturopathic students. Vaccine. 2004;22(3-4):329-334.
    9.     McMurtry A, Wilson K, Clarkin C, et al. The development of vaccination perspectives among chiropractic, naturopathic and medical students: a case study of professional enculturation. Adv Heal Sci Educ. 2015;20(5):1291-1302. doi:10.1007/s10459-015-9602-4
    10.     Busse JW, Walji R, Wilson K. Parents’ experiences discussing pediatric vaccination with healthcare providers: A survey of Canadian naturopathic patients. PLoS One. 2011;6(8).
    11.    Wilson K, Busse JW, Gilchrist A, Vohra S, Boon H, Mills E. Characteristics of Pediatric and Adolescent Patients Attending a Naturopathic College Clinic in Canada. Pediatrics. 2005;115:e338-e343.
    12.    Frawley JE, Foley H, McIntyre E. The associations between medical, allied and complementary medicine practitioner visits and childhood vaccine uptake. Vaccine. 2018;36(6):866-872. doi:10.1016/j.vaccine.2017.12.036
    13.    Downey L, Tyree PT, Huebner CE, Lafferty WE. Pediatric vaccination and vaccine-preventable disease acquisition: associations with care by complementary and alternative medicine providers. Matern Child Health J. Nov 2010;14(6):922-930.
    14.     NAPCP approves position paper on immunizations. Commun Dis Epidemiol Immunization Q [Internet]. Seattle, WA: Department of Public Health, Seattle and King County; 2016(quarter 4):6-7 [cited 2019 Nov 14]. Available from: www.kingcounty.gov/depts/health/communicablediseases/~/media/depts/health/communicable-diseases/documents/cases/communicable-disease-newsletter-2016-Quarter-4.ashx.
    15.    Logan AC, Goldenberg JZ, Guiltinan J, Seely D, Katz DL. North American naturopathic medicine in the 21st century: Time for a seventh guiding principle - Scientia Critica. Explore (NY). 2018 Sep;14(5):367-372.
    16.    Moore A, Harnden A, Grant CC, Patel S, Irwin RS; CHEST Expert Cough Panel. Clinically Diagnosing Pertussis-associated Cough in Adults and Children: CHEST Guideline and Expert Panel Report. Chest. 2019;155(1):147-154. doi:10.1016/j.chest.2018.09.027
    17.    Tiwari T, Murphy TV, Moran J. National Immunization Program, CDC. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines. MMWR Recomm Rep. 2005;54(RR-14):1-16.
    18.     Sprauer MA, Cochi SL, Zell ER, et al. Prevention of secondary transmission of pertussis in households with early use of erythromycin. Am J Dis Child. 1992;146(2):177-181. doi:10.1001/archpedi.1992.02160140043018.
    19.     Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database Syst Rev. 2007;(3):CD004404. Published 2007 Jul 18. doi:10.1002/14651858.CD004404.pub3
    20.     Langdon A, Crook N, Dantas G. The effects of antibiotics on the microbiome throughout development and alternative approaches for therapeutic modulation. Genome Med. 2016;8(1). doi:10.1186/s13073-016-0294-z
    21.     Bardenheier B, Yusuf H, Schwartz B, Gust D, Barker L, Rodewald L. Are parental vaccine safety concerns associated with receipt of measles-mumps-rubella, diphtheria and tetanus toxoids with acellular pertussis, or hepatitis B vaccines by children? Arch Pediatr Adolesc Med. 2004;158(6):569-575.
    22.     Salmon DA, Dudley MZ, Glanz JM, Omer SB. Vaccine hesitancy: Causes, consequences, and a call to action. Am J Prev Med. 2015;49(6 Suppl 4):S391-8. doi:10.1016/j.amepre.2015.06.009
    23.     Lemaitre T, Carrier N, Farrands A, Gosselin V, Petit G, Gagneur A. Impact of a vaccination promotion intervention using motivational interview techniques on long-term vaccine coverage: the PromoVac strategy. Hum Vaccin Immunother. 2019;15(3):732-739.
    24.     Boon HS, Cherkin DC, Erro J, et al. Practice patterns of naturopathic physicians: results from a random survey of licensed practitioners in two US States. BMC Complement Altern Med. 2004;4:14. Published 2004 Oct 20. doi:10.1186/1472-6882-4-14.
    25.     Alexander K, Lacy TA, Myers AL, Lantos JD. Should pediatric practices have policies to not care for children with vaccine-hesitant parents? Pediatrics E-pub ahead of print September 2, 2016. doi:10.1542/peds.2016-1597
    26.     AANMC core competencies of the graduating naturopathic student [Internet]. Washington, DC: Association of Accredited Naturopathic Medical Colleges; 2019 [cited 2020 May 25]. Available from: https://aanmc.org/wp-content/uploads/2019/10/Competencies_Amended_10.25.19.pdf.
    27.     Bean SJ, Catania JA. Immunology beliefs as a factor in vaccine opposition among complementary and alternative medical providers. SAGE Open Med. 2018;6:205031211880762. doi:10.1177/2050312118807625
    28.     Caulfield T, Rachul C. Supported by science? What Canadian naturopaths advertise to the public. Allergy Asthma Clin Immunol. 2011;7(1):14.
    29.     Bradley RS. Philosophy of naturopathic medicine. In: Pizzorno JE Jr, Murray MT, eds. Textbook of natural medicine. 4th ed. St Louis, MO: Churchill Livingstone; 2013.
    30.     NDs for Vaccines [Internet]. 2019 [cited 2020 May 24]. https://ndsforvaccines.com/.
    31.     Regulated states and regulatory authorities [Internet]. Washington, DC: American Association of Naturopathic Physicians; 2019 Jul. Updated 2020 Jul 29 [cited 2019 Nov 24]. https://naturopathic.org/page/RegulatedStates#.

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