Parental Rejection to Vaccination. A Tetanus Case Report, La Libertad, Perú

Introduction

Worldwide, there are different vaccination schedules implemented in the health programs of developed and underdeveloped countries, which is beneficial for public health, resulting in a considerable decrease in morbidity and mortality rates in immunopreventable diseases. However, lately, this progress has been affected by the presence of small population groups or people, who oppose, delay or do not want their children to be vaccinated [1].

In Peru, In Peru, the Ministry of Health establishes the compulsory National Vaccination Scheme and begins in the newborn during his first attention in a health establishment (BCG and HVB vaccines) and then the responsibility to comply with the vaccination scheme lies with the parents or guardians, presenting a problem that should involve the whole society, because although those responsible for the child have the power to decide about their health, they should not make a decision that affects the rights or welfare of the child [2, 3].

Tetanus is a worldwide disease, of low prevalence in countries with vaccination programs. However, the real magnitude of the problem is unknown, due to incomplete notification, but it is acknowledged as a priority health problem in developing countries, such as ours, where in the last three years, 13 cases of tetanus have been reported with three deaths, from which La Libertad Region-Perú leads the first place with a total of five cases and one death. The lethality rate of tetanus is high, reaching 80%.

There is no natural immunity against tetanus, but it is obtained through vaccines or the administration of Tetanus Inmune Globulin. The main symptoms are trismus, sardonic laughter, abdominal or opisthotonic stiffness and dorsal stiffness, culminating with ventilatory mechanic problems, which could end up in death [4].

The reasons that parents defend not to vaccinate their children are varied and are based on religious beliefs or family influences as well as the fear of adverse reactions since they do not have the necessary knowledge or scientific information to make correct decisions. But when emphasizing the rejection of vaccines there is a legal loophole, to what extent is the child's health being jeopardized if it is decided not to put a vaccine considered basic? At this point, we are forced to report a clinical case in La Libertad Region-Peru, which culminated in a fatal outcome when a non-vaccinated girl infected with tetanus died because of religious beliefs [5].

Case Report

A three-year-nine-months-old female patient, from Viru - Nuevo Chao - Trujillo, La Libertad, of low socioeconomic status, and with incomplete vaccination scheme (only received the Bacillus Calmette-Guerin vaccine known by its acronym BCG and vaccine against hepatitis B known by its acronym HVB at the time of birth), due to parental refusal throughout this period, despite the visit and instruction of the corresponding health personnel; assuming that vaccines are unnecessary, alegated by their religious beliefs, adding up an incomplete level of primary education.

The clinical picture begins 12 days before admission, with demanding cough that made her face “red”, so she is taken to a local health center where, after physical examination, it is informed that she has injuries in her lips and throat, prescribing paracetamol and amoxicillin. In the following days, the evolution of the patient is aggravated by presenting unquantified thermal rise sensation, erasure of the left nasogenian fold, multiple ulcerated wounds in cheeks, lips and gums, trismus, hyperextension of both lower limbs in supine position, hypertonicity, no meningeal signs and opisthotonic activated by stimulus. Complementary examinations were performed including non-contrast brain CT, MRI, lumbar puncture and other biochemical exams, obtaining results within normal values. She received timely treatment with Human Tetanus Inmune Globulin and antibiotic therapy with Metronidazole.

The patient is treated for 9 days, after which she presented discrete improvement to treatment; however, the parents request voluntary discharge which was denied by the doctors, being ratified in the first instance by the crime prevention prosecution. The parents appeal this first ruling, accepting their request to withdraw the girl by the prosecutor on this new occasion, thus proceeding with the voluntary discharge. Returning home, the patient suffers a decompensation being taken back to the hospital but dies during the transfer.

Subsequently, the family receives a domiciliary visit by health workers with the aim of vaccinating the whole family due to considering it a tetanus risk area, however the parents refuse to vaccinate themselves as well as to their other children, who have an incomplete vaccination schedule [6, 7].

Discussion

At present, tetanus is a controlled disease, thanks to the simple and free access to vaccination, however in the last 10 years, 15 cases have been reported in the La Libertad Region of Peru, among which is the case of this patient who was diagnosed with tetanus based on the clinic, history of injuries and geographic area with a high incidence of this disease, but above all, to an omission of protection by the parents, who refused to vaccinate at the appropriate time. According to the WHO, this action could be considered as child abuse, because within its definition it mentions the following: “All forms of physical and / or emotional abuse, sexual abuse, neglect or negligent treatment, commercial or other exploitation type, of what results in a real or potential harm to the health, survival, development or dignity of the child” [8].

The patient was hospitalized with the diagnosis of tetanus, therefore, she received the corresponding management for the disease, presenting slight improvement on the fifth day of admission, however, the parents refused to continue the treatment requesting voluntary discharge and because of the refusal the physician, they went to the prosecutor, who agreed to have the patient discharged, leading to the fatal outcome within a few hours of nosocomial withdrawal. For what is referred to in this case, in our country, the action of not complying with the National Vaccination Scheme, is not considered as child abuse, a fact that contradicts as stipulated by WHO [1].

The Peruvian state has the duty to ensure the health and well-being of minors, for this reason if parents decide not to vaccinate their minor children, without acknowledging the risk involved, meaning death in many cases, the state should intervene vigorously through the Municipal Ombudsman for Children and Adolescents (DEMUNA) or the National Institute for Child and Family Welfare (INABIF). It is also vitally important that health personnel strictly monitor children under 5 years of age who do not have a complete vaccine schedule [1].

However, the main problem of non-vaccination is that parents flatly refuse to vaccinate their children, using arguments without scientific basis but that are widespread and socially entrenched. On the other hand, a second problem is added to this decision, in which the medical professional, can consider the risk that, from a public health standpoint, there are unvaccinated children and therefore vulnerable to infection, susceptible to its spread. As we can realize, this leads us to an ethical dilemma; the medical professional can choose between two extreme alternatives: first; consider that exists parental negligence by not vaccinating their children and reporting it. The second option is to consider that it is merely a matter related to the parents and there is nothing to do with it. Either end is inappropriate and you have to find intermediate solutions in which children are the only beneficiary [4, 9].

In the preventive activity of vaccination, the principle of beneficence must prevail, since it is an action that is not aimed at combating harm or disease, but rather at avoiding it. This principle must be applied relative to that of the patient's autonomy, in this case represented by her parents, who did not consent. On the other hand, by preventing potentially serious diseases through a simple action, their omission could violate the principle of non- maleficence, of a higher rank than the previous two. The application of the principle of justice is also in favor of vaccination, as community health is at stake [10].

Conclusions

The reluctance to vaccination for false beliefs based on myths, lack of information, mistrust in health workers and fear of adverse effects causes serious damage to children's health. Therefore, it is of vital importance to strengthen health strategies framed in the law in order to preserve the health of children without violating parental autonomy to decide what is best for their children.

Conflict of Interest

The authors of the study declare that there is no conflict of financial interests regarding the preparation and conduction of this study.