Understanding Immunisation Safety And Addressing Parental Concerns

Question 1A: Develop a researchable question related to immunisation.

You are working as a registered nurse in a GP Practice and one of your roles is to promote immunisation for children (this may be the MMR or other recommended immunisations).  You have had a few parents refuse vaccinations for their children and this concerns you as you believe that this may leave the child and communities vulnerable to outbreaks of serious diseases. 

You do not think that parents would deliberately expose their children to the risk of serious disease unless they were guided by a belief that immunisation was not safe.   You are vaguely aware via media reports that there is an anti-vaccine movement, and you want a quick overview of what it is all about. As most of us would do, you consult Google, and you find the following information. Read the information video below:

The History of Vaccines: History of the anti-vaccination movement The College of Physicians of Philadelphia (2017)

You could now choose the following actions:

• Conclude that parents are entitled to make decisions about their child’s healthcare, even if it is against public health policy.
• You could question your own belief system – after all, you are basing your practice on government guidelines and you trust that the government will make decisions about health care that are evidence-based, informed by experts in the field, and in the best interests of Australians. You haven’t checked the literature for evidence of immunisation safety yourself.
• You could investigate whether there is any evidence of harm caused by immunisation, and to identify information that may influence parent’s beliefs or fears about immunisation.

Naturally, you are a great nurse with an inquiring mind. You want to be certain that there is good evidence that demonstrates that immunisations are safe for children.  You want to understand what information has led parents to be concerned about immunisation. Finally, you want to be able to have an informed discussion with the parents about their concerns based on current evidence to help them make the right decision for their children. 

Question 1 (20 marks) (400 word equivalent)

Question 1A

After reading the background information, develop a researchable question from the background information that you have been given relating to immunisation. This question can be suited to quantitative or qualitative methods.  Type your question below:

Is the recommended vaccines compulsive used to children are safe to the children immunization programs? P: children I: use of vaccine C: recommended vaccines compulsive or voluntary O: safe to the children immunization programs

 Question 1B:  List three sources of information that would provide you with the best (strongest) evidence that would enable you to answer your research question.  For each of the three sources, give an example of the type of information that would be available to you from this source.

*The examples provided below represent a source of information and a type of information available from that source. It is not suggested that these are the best sources of evidence. 

Source of information	Type of information
The NCBI website	The website would give studies in form of clinical trials concerning the use of vaccines in health
The NIH website	This would provide the recommended level of safety in the use of vaccines in children
World Health organization, department of vaccines, immunizations and biological	A guide on conducting an expanded programme on immunizations (EPI) review

 Question 1C: List five search terms that would assist you to find suitable literature to answer your question.  For each of the search terms, suggest an alternate word for which the Boolean function “or” could be used.

Keyword	Search term for Boolean ‘or”
1	Vaccination or immunization
2	Safety or efficacy
3	Health or wellbeing
4	Side effects or adverse reactions
5	Evaluate or determine

 

Question 1D: If your search failed to find a satisfactory number of quality articles, outline the actions that you could take to improve your search results. 

Question 1B: List three sources of information that provide the best evidence for answering the research question.

If no enough number of  article about this subject can be  found, then a number of strategies will be adopted  to ensure that as many materials as possible are found. The strategies to increase the number of search results are by searching multiple databases, likes library websites and health databases to search for articles, to modify the keyword and question, or to break down the research questions into   PICO/PIO elements and work out the concepts for each PICO/PIO elements. To develop the search strategies by vary the expression or keywords for each concept with the use of abbreviation , tuncation , wildcard and phrase searching and so on. Turncation identifies different variations of a word. Using truncation will broaden the search. Frequently used truncation symbols include the asterisk (*), or a question mark(?) .

For example, to search the word “nurse”, use truncation nurs* will broaden the search. The wildcard will help to spell the identical word in different ways which is to obtain different spelling of the same word. Another method is to use the quotation marks when referring to certain exact phrases in a search sentence. Once the quotation marks are added to a search phrase, the returned results are specific to the words used, thus limiting the number of returned search pages.  Often uses a ? as a wildcard  symbol. For example: randomi?ation can found in the research articles in two different spellings: Randomisation and Randomization. The method phrase searching is to examine two or more words as an exact phrase.

Phrase searching includes double quotation marks (“  ”) around two or more words to create a search term. For instance: “genetic engineering” will search for results includes the word “ genetic” and “engineering” will appear next to each other. Additionally, apply Boolean operators correctly such as: and, or, not, to expand or narrow the search depending on the search terms. Use thesaurus to find out more suitable search terms. Use keywords more focused on the research question. Moreover, the advanced option can be clicked on the browser so as to refine the results based on country, date, language, year of publication article typing and much more information as may be required.q

uestion 2 (40 marks) (800 word equivalent)

Complete the attached table with the relevant information from each of the four articles. Do not use dot points.

Table 1. Meta-analysis (+/- systematic review)
Full reference: Nursing	Taylor, L.E., Swerdfeger, A.L. and Eslick, G.D., 2014. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine, 32(29), pp.3623-3629. Access via
Search strategy	Citation searching
Inclusion/exclusion criteria	The included studies in this research were those involving case controls and cohort studies concerning the possible link between autism and vaccinations. Additionally, only information from databases such as PubMed, EMBASE, Google Scholar and MEDLINE, published up to April 2014 were considered for this research. Therefore the included materials were five cohort studies that had 1,256,407 children, and another five case-controls that had 9,920 children. Any other studies that never met the above criteria was excluded from the study.
Issue  (what was being  studied)	The research was studying the argument that the vaccines are not associated with development of autism.
Context (study setting)	This study involved database searches by use of controls and cohort studies involving the possible link between the use of vaccines and development of either autism or autism spectrum disorders (Taylor et al., 2014). There were two reviewers who extracted the available data concerning the study features, methods used and the results found. In case of possible disagreements, they were resolved by a way of consensus with a different author.
Outcome (main findings)	This article found out that there was no any relationship between vaccination and autism and autism spectrum disorders (Offit, 2013). Additionally, there was no relationship between autism and MMR or thimerosal, a compound used in the preservation of vaccines. For the case control data, there was no relationship found between increased risk of autism or autism spectrum development disorder upon use of mercury, MMR or thimerosal by either grouped condition or grouped exposure. Thus the components of vaccines, i.e. the mercury and thimerosal, as well as multiple vaccines are not linked to the development of autism or autism spectrum disorder.

Table 2. Systematic review
Full reference Nursing	Jefferson, T., Price, D., Demicheli, V., Bianco, E. and European Research Program for Improved Vaccine Safety Surveillance (EUSAFEVAC) Project, 2003. Unintended events following immunization with MMR: a systematic review. Vaccine, 21(25-26), pp.3954-3960. Access via ScienceDirect Journals (Available from 1995 volume: 13)
Search strategy	Citation strategy
Inclusion/exclusion criteria	The studies included in this research were those of either comparative prospective or retrospective nature, among healthy people, and aged exactly 15 years. Additionally, these studies were required to have been either carried out or conducted in 2003.
Issue  (what was being  studied)	The aim of this research was to determine the events of following immunization with MMR, through a systematic review. This is following several debates concerning the safety of this trivalent vaccine and the continued drop in the vaccination rate in various countries (Jefferson et al., 2003).
Context (study setting)	The study setting involved the carrying out of a systematic review to determine whether there is evidence of unintended side effects either good or bad, when people receive the MMR vaccine. Moreover, this study assessed whether systematic review methods can be applicable in evaluating safety aspects. While about 120 studies were found to satisfy the study criteria, only 22 of them were used for this study.
Outcome (main findings)	This study found out that the MMR vaccines are associated with the upper respiratory tract infections, irritations, and possible development of benign thrombocytopenic purpura, joint pain and aseptic meningitis, as compared to the placebo. Additionally, it was found that the use of MMR vaccine is not likely to be associated with the Crohn disease, autism, aseptic meningitis and ulcerative colitis. The use of systemic reviews in reporting of safety outcomes about MMR vaccines was not found to be adequate enough.

Table 3. Experimental quantitative studies
Full reference: Nursing	Prymula, R., Bergsaker, M.R., Esposito, S., Gothefors, L., Man, S., Snegova, N., Štefkovi?ova, M., Usonis, V., Wysocki, J., Douha, M. and Vassilev, V., 2014. Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine versus one dose of monovalent varicella vaccine: a multicentre, observer-blind, randomised, controlled trial. The Lancet, 383(9925), pp.1313-1324.
Study Design (e.g.: cohort, RCT,)	This was a randomized controlled trial
Population (how many participants, age, gender, disease, etc)	This research involved healthy children aged between two to twenty two months, who were to receive two types of doses of either the MMRV or MMR dose, at 42 days apart (Prymula et al., 2014). However, this study involved 5,803 children but the gender composition of the sample is not given. The children used as the study sample, were healthy initially, but in this case they were admninsteres one dose of varicella, or two doses of MMRV vaccines respectively, to determine the possibility of protection against varicella.
Intervention (what was being implemented)	The administration of either a single dose of varicella vaccine, or two doses of MMRV vaccine.
Comparison (was the intervention being compared to another strategy, e.g. placebo?)	Yes, the use of comparison was done, whereby the cintervention group received either two doses of MMRV, or MMR and varicella vaccine, while the control group received two doses of MMR. This was done for the comparison of the results.
Outcome (main findings)	There were 37 confirmed cases of varicella among the MMR group. The findings of this research supports the use of two doses if varicella vaccine on a short course, so as to ensure that there is optimum protection from any form of varicella disease. In the MMR and Varicella vaccine group, there were 243 cases, while in the MMRV group, there were 201 cases. The efficacy of a two-dose MMRV against varicella was at 94.9%.

Table 4. Qualitative study
Full reference Nursing	Guillaume, L.R. and Bath, P.A., 2004. The impact of health scares on parents’ information needs and preferred information sources: a case study of the MMR vaccine scare. Health Informatics Journal, 10(1), pp.5-22.
Study Design (ie: cohort)	This was a questionnaire based study design
Population (how many participants, age, gender, disease, etc)	This study involved seventeen questionnaire administered among parents in the UK. The age and gender information about the participants is not provided in this article. However, the research aimed at determining the scare resulting from the measles, mumps and rubella vaccination, and its impact on the parents of children (Guillaume and Bath, 2004).
Issue  (what was being  studied)	It was aimed at studying whether the MMR vaccine caused any scare among the parents of young children, and whether there was effects to the need for additional information about the same.
Context (study setting)	This study was conducted as a result of increased cases, of mass media reports on the panic arising from health issues and interventions, because those involved need information.
Outcome (main findings)	It was found that the health scares increased the need for more information by the parents of the young children in terms of making decisions on whether their children would be determined or not. In this case, the parents did not value the traditional information about MMR vaccinations since they were not viewed to be trust worthy (Yang, 2014).

 Question 3  – 800 words

• Discuss the reasons that the studies above would or would not be helpful in enabling you to have an informed discussion with parents about immunisation for their children. Comment on the relative value of the studies to your argument. Use supporting evidence where appropriate. 

Since the history of vaccines, and vaccinations, there have been controversies concerning its efficacy and safety. Most of the issues raised against the vaccinations is concerning the side effects as well as the ethics part of it. There are some vaccines like the MMR which have been reported to have some serious side effects (Jain et al., 2016). However, there are several research studies conducted to confirm this, but no agreeable results are given. In other case, the parents based on various beliefs and religion beliefs argue that the manner in which the vaccines are developed and administered is not within their religious traditions. As a result of this, there have been ongoing debates on whether to use vaccines or not.

Question 1C: List five search terms and their Boolean ‘or’ alternatives to find relevant literature.

On the other hand, the governments in various countries have put strict regulations and policies concerning the need for the parents to have their children vaccinated, bearing in mind the disease outbreaks which are quite difficult and expensive to treat (Taylor et al., 2015). Therefore, generally, vaccination is an important program in public health. According to the governments, the issue of vaccination decision is not a decision that the parents or the families can make for themselves. Based on clinical evidence, the vaccines are important and work in two major ways: first is that they decrease the risk of contracting a disease, and second, they lower the number of potential carriers of a disease in a population, and hence improved health outcomes. Therefore, the ore the number of vaccinated people, the more difficult it is, for a disease to spread (Uno et al., 2015). For the case, of children, vaccination confers herd immunity among children, especially for those who are too weak or too young to be vaccinated. But the question really is, what makes people to get scared about immunizations?

It is true that the people with a weakened immune system are not fit to get vaccines like measles, mumps and rubella, because such people can possibly end up with inflammation in the brain, encephalitis and in other cases, they can die. However, the parents need to understand that these side-effects, even though they might occur, they are quite rare (Horne et al., 2015). Furthermore, if people are infected, say with measles, this condition can cause its own risks of other cases like encephalitis. Even though there are some negative side effects associated with the use of vaccines, the benefits are much more.

These studies discussed above could be quite helpful to me in making informed decisions concerning the parent’s anti-vaccination ideologies (Gale, 2017). For instance, the study by Taylor et al., 2014, is clear enough in the establishment of the possible thought link between vaccinations and the development of autism or autism spectrum disease (Foster and Ortiz, 2016). After the consideration of a number of literature, this author finds that there is no relationship between the MMR vaccine and the development of autism or autism spectrum disorders (Jain et al., 2015). Since this study was carried out using proper design and methodologies, then the findings are clear enough to convince me that truly, the vaccines are and immunization programs are safe and effective. 

Question 1D: Outline methods to improve search results if insufficient quality articles are found.

However, the study by Jefferson et al., 2003, reports that the use of the MMR vaccines is likely to cause some side effects such as the upper respiratory tract infections. All in all, although some of the said side effects are true, the benefits are truly so much more. Additionally, according to the risks, the parents in the article by Guillaume and Bath, 2004, report that such anti-vaccination scares are important because they keep the parents of the young children who need to be vaccinated, aware of the recent information concerning the use of vaccines, and therefore avoid, old literature materials which could be unreliable.

The history of compulsory vaccinations against small pox repeats the situation that is happening concerning the current vaccination controversies (Yaqub et al., 2014). At the moment, the vaccination debate is associated with some crucial questions concerning the government policies making vaccinations compulsory. If one fears that their children might get contaminations with vaccination, or the method of vaccination, for instance the one on small pox was associated with the vaccination material.

For instance, in the United States, the small pox vaccine helped many people to reduce the risks of small pox which many years ago was a deadly disease (Yale, 2014). However, the method of vaccination, especially by public health officials was deemed unsanitary and quite unsafe especially to the people of low social-economic status, due to the arm-to arm administration method. The policy of vaccination being a compulsory undertaking by all citizens is in the process of the government acting in common good for the people’s health (Peretti-Watel et al., 2013). Despite the continued objections towards the issue of vaccinations, the health practice been important in preventing the spread of many diseases. Although they are not risk-free, they are a bit safer than any other treatment methods. Considering the risk of some diseases like tuberculosis and some viral infections, the use of vaccines, is the best prevention method. 

Reference List

Foster, C.A. and Ortiz, S.M., 2016. Vaccines, Autism, and the Promotion of Irrelevant Research: A Science-Pseudoscience Analysis. Skeptical Inquirer.

Gale, S.G., 2017. Autism and Vaccinations: The False Correlation.

Guillaume, L.R. and Bath, P.A., 2004. The impact of health scares on parents’ information needs and preferred information sources: a case study of the MMR vaccine scare. Health Informatics Journal, 10(1), pp.5-22.

Horne, Z., Powell, D., Hummel, J.E. and Holyoak, K.J., 2015. Countering antivaccination attitudes. Proceedings of the National Academy of Sciences, 112(33), pp.10321-10324.

Jain, A., Marshall, J., Buikema, A., Bancroft, T., Kelly, J.P. and Newschaffer, C.J., 2015. Autism occurrence by MMR vaccine status among US children with older siblings with and without autism. Jama, 313(15), pp.1534-1540.

Jain, A., Marshall, J., Buikema, A., Bancroft, T., Kelly, J.P. and Newschaffer, C., 2016. Correction of Description of MMR Vaccine Receipt Coding and Minor Errors in MMR Vaccine and Autism Study. Jama, 315(2), pp.202-204.

Jefferson, T., Price, D., Demicheli, V., Bianco, E. and European Research Program for Improved Vaccine Safety Surveillance (EUSAFEVAC) Project, 2003. Unintended events following immunization with MMR: a systematic review. Vaccine, 21(25-26), pp.3954-3960

Offit, P.A., 2013. Vaccinations and Autism. Encyclopedia of Autism Spectrum Disorders, pp.3211-3212.

Peretti-Watel, P., Verger, P., Raude, J., Constant, A., Gautier, A., Jestin, C. and Beck, F., 2013. Dramatic change in public attitudes towards vaccination during the 2009 influenza A (H1N1) pandemic in France. Eurosurveillance, 18(44), p.20623.

Prymula, R., Bergsaker, M.R., Esposito, S., Gothefors, L., Man, S., Snegova, N., Štefkovi?ova, M., Usonis, V., Wysocki, J., Douha, M. and Vassilev, V., 2014. Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine versus one dose of monovalent varicella vaccine: a multicentre, observer-blind, randomised, controlled trial. The Lancet, 383(9925), pp.1313-1324.

Taylor, L.E., Swerdfeger, A.L. and Eslick, G.D., 2014. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine, 32(29), pp.3623-3629.

Taylor, L.E., Swerdfeger, A.L. and Eslick, G.D., 2014. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine, 32(29), pp.3623-3629.

Uno, Y., Uchiyama, T., Kurosawa, M., Aleksic, B. and Ozaki, N., 2015. Early exposure to the combined measles–mumps–rubella vaccine and thimerosal-containing vaccines and risk of autism spectrum disorder. Vaccine, 33(21), pp.2511-2516.

Yang, J.H., 2014. Parents still harbor fears about Autism-vaccine link. Journal of Developmental & Behavioral Pediatrics.

Yaqub, O., Castle-Clarke, S., Sevdalis, N. and Chataway, J., 2014. Attitudes to vaccination: a critical review. Social Science & Medicine, 112, pp.1-11.