What Is the Alternative Vaccine Schedule?

Last Editorial Review: 11/2/2010

Experts debate the pros and cons of the alternative vaccine schedule, and what it means for parents.

By Katherine Kam
WebMD Feature

Reviewed by Laura J. Martin, MD

When pediatrician Robert W. Sears, MD, FAAP, wrote The Vaccine Book: Making the Right Decision for Your Child, he envisioned giving parents more choices on how to vaccinate their children if they were concerned about a vaccine's side effects or ingredients or the large number of shots that kids receive today.

"A lot of parents don't really trust the vaccine system," Sears says. "I felt that if I could give parents a better understanding of vaccines -- as well as an alternative way to approach giving vaccines -- then these families who otherwise might not vaccinate could go ahead and feel comfortable with vaccinating."

Sears, who practices in San Juan Capistrano, Calif., says that he isn't against vaccinations. Instead, his book suggests an untraditional "alternative" schedule that delays shots or spaces them further apart. If parents are skittish about any shots at all, he offers a separate "selective" schedule to encourage them to give their kids at least the "bare minimum" of vaccinations.

But public health officials say that those approaches leave too many kids unprotected for too long and aren't backed up by science.

"These altered schedules have not been studied at all," says Meg Fisher, MD, a pediatric infectious disease specialist and medical director of the Children's Hospital at Monmouth Medical Center in New Jersey and chair of the American Academy of Pediatrics' section on infectious diseases. "I would rather stay with what we know is the most likely to protect the most people."

Regular, Alternative, Selective Vaccine Schedules

The regular vaccine schedule for children aged 0-6 is approved by the CDC, American Academy of Pediatrics (AAP), and the American Academy of Family Physicians.

It recommends 25 shots in the first 15 months of life. The shots immunize against whooping cough (pertussis), diphtheria, tetanus, mumps, measles, rubella, rotavirus, polio, hepatitis B, and other diseases.

The alternative and selective vaccination schedules aren't reviewed or approved by the CDC or other public health group. They come solely from Sears.

Sears' alternative vaccine schedule spreads the shots out over a longer period of time, up to age 5-6 years. For instance, he recommends not giving kids more than two vaccines at a time. It also changes the order of vaccines, prioritizing what Sears believes are the most crucial vaccines to get, based on how common and severe the diseases are.

As Sears writes, "If some of the theoretical problems with vaccines are real, this schedule circumvents most of them. If the problems aren't real, then the only drawback is the extra time, effort, and cost for the additional doctor's office visits."

For parents who are the most reluctant to vaccinate, his selective vaccination schedule includes what he calls the "bare minimum" vaccinations against serious and common diseases, such as whooping cough and rotavirus. It also omits some vaccines, including the one for polio.

Number, Timing of Vaccinations

Many parents are wary of the regular vaccine schedule because of the number of shots kids get. Not only do children receive more vaccines than in the past, but sometimes, they get multiple immunizations in one visit.

In his book, Sears writes that his alternative vaccine schedule "does eventually provide complete protection from diseases, and it does so at an age-appropriate pace. It gives kids protection from diseases at the ages when those diseases are the most troublesome, and it doesn't necessarily overload young kids with vaccines that they don't really need until they're older."

The problem is that vaccine timing is critical, Fisher says. Shots are scheduled at the earliest possible age and at the stage when the vaccine will work best with the immune system, she says.

"Let me give you a feel for why the schedule is the way it is. We know that a baby is born with the antibodies from the mother at the time of birth. During the last trimester of pregnancy, the immunoglobulin of the mom crosses the placenta and gets into the baby. The baby's born with very good protection at birth for a lot of the dangerous organisms that we worry about," she says.

"However, that protection… is halfway gone in a month. So each month, the baby has less and less of the antibody from the mom to protect it. So by giving those main immunizations in the first six months of life, we're actually stimulating the baby's immune system so that the baby's making their own antibody at the same time they're losing their mother's antibody, so that it doesn't leave them unprotected."

Melinda Wharton, MD, MPH, deputy director of the CDC's National Center for Immunization and Respiratory Diseases, is aware that the large number of shots concerns parents. But, she says, "The biggest problem with spacing vaccines over a long period of time is that a child remains susceptible to disease longer than they need to. I wouldn't want my children to be at risk of something that I could prevent."

Lack of Vaccination Carries Risk

Many parents worry about side effects from the measles-mumps-rubella vaccine, Sears says. It was this vaccine that triggered the autism debate more than a decade ago. Numerous studies have shown no link between the two.

In his book, Sears suggests that if parents are comfortable, their children should start the MMR shot on the regular schedule at 12 months of age. But worried parents can delay the first MMR shot until their child enters day care or school. "You could safely delay the vaccine until your child enters school, since he is unlikely to come into contact with anyone who has one of these three illnesses," he writes.

Statistically, a child in the U.S. has an extremely low risk of catching measles; fewer than 100 cases are reported annually in this country, according to the CDC. But outbreaks of the highly contagious viral illness have occurred among unvaccinated kids. In 2008, an unvaccinated 7-year-old boy who had visited Switzerland came home to San Diego and developed measles. An additional 11 unvaccinated children, aged 10 months to 9 years, became infected, including four who had been in the pediatrician's office at the same time as the 7-year-old boy. In some cases, measles can lead to severe complications, including encephalitis, pneumonia, and death.

Public health experts consider such risks unacceptable, but Sears sees it differently. Most of the children who caught measles were unvaccinated because their parents chose to accept that risk, he says. "I tell these parents that it's really not much risk to leave your baby or toddler unvaccinated against measles, as long as the majority of families are vaccinating around you. Now, I'm not telling parents that they should do this. I'm just telling them that they need to understand what the risks might or might not be, and for that particular disease, the risk is very, very low for families who delay the vaccine."

Trying to protect one's unvaccinated children by surrounding them with vaccinated children is a concept called "herd immunity."

But herd immunity isn't foolproof, experts say, because diseases can be "imported." Fisher cites a 2007 case in which a boy, aged 12, visited from Japan to play in a Little League series. He was infected with measles, and investigators linked his illness to six later measles cases in Pennsylvania, Michigan, and Texas.

Sears says that leaving children unvaccinated does increase risk. "Honestly, the best thing is to go ahead and vaccinate so that you don't take those kinds of risks," he says. "But I'm simply willing to understand and work with the parents who would rather take the disease risk of measles than the vaccine risk."


Childhood Diseases: Measles, Mumps, & More See Slideshow

Personal Choice, Social Responsibility

The debate over Sears' book highlights the conflicts between individual choice and social responsibility.

"Clearly, keeping vaccination rates high and following the regular vaccination schedule is in our nation's best interest from a public health standpoint," Sears says. "I'm trying to help… individual families understand how to make vaccine decisions for their own child. Parents really don't look at the public health's best interests when they're making vaccine choices. I find that they're inherently more selfish about their own children's health. I don't mean ‘selfish' in a negative way; they're just naturally thinking about their own child much more than what might be in the best interest of our entire nation. To me, that seems like a natural way for any parent to approach the decision."

Fisher says that approach is risky. "If you want to use individual choice -- so you say, 'OK, I'm not going to let my child risk a reaction to the vaccine because everybody else is getting immunized, so my child's going to be protected by the herd' -- that, to me, is almost an abuse of the idea of the public health system."

She says the CDC's vaccine schedule has been used for decades, but "we don't know what happens with these alternative schedules or whether or not we will have the same public health impacts."

Furthermore, unvaccinated kids can endanger other children who simply can't be vaccinated, such as those who are too young or too sick or have a compromised immune system. Public health officials have cited unvaccinated children and adults as one of the reasons behind California's recent whooping cough epidemic. Ten babies have died in that epidemic, all of them too young to have been fully immunized against the disease.

"If there's a reason your child can't be immunized, then you're really counting on everybody else being immunized so that they don't expose your child," Fisher says.

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Robert W. Sears, MD, FAAP, pediatrician, San Juan Capistrano, Calif.; author, The Vaccine Book: Making the Right Decision for Your Child.

Meg Fisher, MD, medical director, Children's Hospital at Monmouth Medical Center, Long Branch, N.J.; chair, section of infectious diseases, American Academy of Pediatrics.

Melinda Wharton, MD, MPH, deputy director, National Center for Immunization and Respiratory Diseases, CDC.

American Academy of Pediatrics: "The Childhood Immunization Schedule: Why Is It Like That?"

CDC: "2010 Recommended Immunizations for Children from Birth Through 6 Years Old."

CDC, Morbidity and Mortality Weekly Report, Feb. 22, 2008; early release.

Reviewed on November 2, 2010

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