Thanks for returning to the second installment of this story. If you haven’t read Part 1, you can find it here. As mentioned before, the patient and family in the story are fictional but the conversations are not!

13-14 years old: HPV vaccination

Sadie, at 13 years old, was the brightest in her year. She loved Maths, History, Art and Science. Her physical health was good, and her asthma, less troublesome. As per usual, she went for her 6-month asthma review to her GP where she met Rachel, a GP trainee. Rachel checked Sadie’s inhaler technique (which was excellent). As part of the history, Rachel checked if Sadie had had the Human Papilloma Virus (HPV) vaccine at school.

“Well, doctor” said Sadie, “my mom told me I should get it because it prevents me from cervical cancer. But mom never got it and is perfectly fine. Also I’ve heard it’s full of metals which are dangerous and toxic. Plus it can cause you to lose power in your legs. Also one of my friends fainted after the vaccine. I’m too scared to get it” 

Rachel was amazed at how articulate and curious Sadie was, and since she had told Rachel how much she enjoyed science, had an in-depth conversation with Sadie about the vaccine. Despite the busy clinic, Rachel felt this was time well spent. Here is the summary of what she explained.

HPV is the most common sexually transmitted virus worldwide, with first infection typically occurring soon after sexual debut. HPV infection causes virtually all cervical cancers and high-grade dysplasias, approximately 90% of anal, 70% of vaginal, 50% of penile, 40% of vulvar, and 13%–72% of oropharyngeal cancers. In the UK, HPV vaccine is offered to girls and recently also to boys at school in year 8 or 9. It involves two injections 6 to 12 months apart. If missed at school, it can be given by the GP until the age of 25 years and comprises 3 injections instead of 2. Studies have shown a dramatic decline in the rate of pre-invasive cervical disease as a result of the HPV vaccine programme. The greatest impact has been seen where the vaccine is routinely given before HPV exposure. In settings which have a high uptake and a catch up programme, unvaccinated women also show a reduction in disease, possibly because of herd protection.

The HPV vaccine has been used in Australia, Canada, USA and some Western European countries for many years before the UK, with more than 100 million people vaccinated worldwide. Despite concerns raised in the

media, no causal links have been found between HPV vaccine and adverse events, such as Guillain-Barré Syndrome (GBS, a rare cause of paralysis). Fainting episodes following HPV vaccination have been reported, but the rates have not been higher than those following receipt of other vaccines for teens. Because of the possibility of fainting, it is recommended to observe teenagers for 15 minutes after getting immunized. Side effects like swelling or pain at injection site has been reported but the benefit of the vaccine far outweigh these minor risks.

Some vaccines (including the HPV vaccine) contain a small amount of aluminium. Aluminium is the third most abundant element on earth after oxygen and silicon, and it is the most abundant metal, making up almost 9 percent of the earth’s crust. Aluminium is found in plants, soil, water, breast milk and air. Typically, adults ingest 7 to 9 milligrams of aluminium per day. Aluminium is used in vaccines as an adjuvant that boosts the immune response allowing for lesser quantities of the vaccine and fewer doses. Extensive trials have proven its safety in vaccines. Have a listen to Dr Paul Offit from Children’s Hospital Philadelphia giving us more information.

She also gave her this NHS leaflet on the HPV vaccine.

Sadie seemed to enjoy the chat, and thanked Rachel for explaining things. She chose to have her HPV vaccine next time it was offered at her school.

The other side…

Years rolled on. Sadie decided she wanted to become a nurse. She worked hard, she was curious and always wanted to know more. Her mom arranged a “work experience day” for her in the same hospital where she was born. Here she met Aimee, a paediatric junior doctor. Aimee invited Sadie to come with her as she examined a 14-month-old girl in ED with a throat infection. Sadie listened as Aimee took the history. She learnt that the young girl was generally well; breast fed as a baby and never been to ED before.

Sadie found out (to her horror) that the child was un-immunised because the family did not believe in vaccines. According to the mom they were full of artificial products, overloading the immune system and unnecessary because the child was very healthy and mostly ate home grown and home cooked organic food (dad was a chef). No junk food or processed food was ever used in her household. The child’s mom went on to say that she thought vaccines were unnecessary because these diseases simply didn’t cause problems anymore – she had never heard of anyone catching measles, mumps or rubella.

Sadie felt angry. She wanted to tell this woman she thought she was mad. She knew Aimee would drill some sense into her.

Aimee, despite a busy Emergency Department, took the time to listen to mom’s concerns. She asked mom respectfully if she wanted to talk more about this. The mom refused. She asked if she could give her some

websites to look at in her own time. Mom agreed to that. So Aimee signposted her to this NHS website for information about vaccine safety.

Aimee advised the child’s mom about signs to look for if ever she became unwell.

Finally she gave mom her contact details and said, “Please let me know if you wish to talk about this in future. If you do decide to get your child-vaccinated – it’s never too late to catch up – contact your GP who will be able to give you advice about the catch up vaccine schedule”.

The mother thanked Aimee for the information and left.

Sadie was shocked. She asked Aimee “What just happened? Why didn’t you drill some sense into that crazy woman? Surely this was the best chance to get the child vaccinated, wasn’t it? That poor child!”

It was time for a break – Aimee made Sadie a cup of tea in the staff room and they chatted about what had happened. Here is the summary of what she said.

Vaccine hesitancy sits on a continuum of acceptance. A vaccine-hesitant person can delay, be reluctant (but still accept), or refuse one, some or all vaccines. Some who choose to get vaccinated continue to have safety concerns. This latter group are important to focus upon to improve their vaccine resilience for future vaccinations. These people are more receptive to public health and health-care providers’ messages than outright vaccine refusers. It is important to respect families who mostly have the child’s best interest at heart. Rather than arguing and disagreeing, it is better to focus on vaccine safety, signpost families and leave an open door for future conversations. We are likely to have more success if we remain non-judgemental.

Sadie reflected on what Aimee said. She was beginning to understand why Rachel’s consultation style (when Sadie worried about having her HPV vaccine) was different to Aimee’s consultation that day. It’s true, one size does not fit all! Being adaptable, respectful and non-judgemental is a skill, and she was going to practice it. She thanked Aimee for an interesting day of work experience.

We would like to conclude here, but will keep an open door for suggestions or requests for Part 3. Who knows where Sadie’s story will take us next?

Authors: Aimee Henry (ST1 Paediatrics), Marty Hanna (ST5 Paediatrics), Vincent McLarnon (Advanced paediatric nurse practitioner), Colm Darby (Advanced neonatal nurse practitioner), Rachel Hearst (GPST2) & Shilpa Shah (Paediatric Consultant)

Craigavon Hospital, Southern Health & Social Care Trust, Northern Ireland