Multi-dose vaccinations - what happens if you miss a dose?

November 23, 2007 1:45 PM

Gardasil is given in 3 doses across 6 months, so what if you decide not to get the the last two doses?

I have custody of my niece, who is 12. At her physical, her doctor recommended the typical booster shots as well as the HepA vaccination and Gardasil, the vaccine against HPV.

I agreed to the vaccinations.

When I checked back with the 12-year old's mother to tell her about the physical and the shots, it turns out that my sister doesn't believe in vaccinations. In particular, she was fearful of new vaccines on the market, like Gardasil. I immediately regretted my decision to allow the vaccinations and kept mum about the Gardasil.

So, what happens if I don't agree to the final two administrations of Gardasil? Will it be as if the 12-year old never got the vaccine, or will she be more susceptible to getting the virus now, or...?

Also, any suggestions on how to come clean with my sister? I am annoyed by my lack of foresight and disappointed that I never sought her consent first.

I do have an appointment to discuss this with the 12-year old's doctor, but it's not for a few weeks and I want to try to defuse the situation as much as possible with my sister. I'm posting anonymously because I don't want my sister to know about this before I tell her.

posted by anonymous to health & fitness (26 comments total)

I seem to recall that my doctor told me that the first shot provides most of the protection, and the 2nd and 3rd act as boosters.
posted by ThePinkSuperhero at 1:56 PM on November 23, 2007 [1 favorite]

To answer your question, I'm almost positive that it's like you never got the vaccine. I've had 2 of the three shots and waiting to get the last shot in December.

And I know it wasn't part of your question or any of my business, but how the hell does one not believe in vaccinations???

Vaccines save lives, money, and a hell of a lot of trouble and illness. I can understand being wary of something fresh out on the market, but some of this other stuff... not only is it mandatory for those who attend public school, it's just plain stupid not to do it. They've been around for ages now and millions have had the vaccines with no problems.

As for newer vaccines, I'd rather take my chances with Gardasil than end up with HPV and possibly cervical cancer down the road.
posted by purelibertine at 1:57 PM on November 23, 2007

In response to the first post... my doctor told me that the first one doesn't have much effect without the later two... or maybe I just misunderstood him.
posted by purelibertine at 1:58 PM on November 23, 2007

I have custody of my niece, who is 12. [...] it turns out that my sister doesn't believe in vaccinations.

But you still have custody, right (assuming that you acculally mean 'custody')? So her mom's irrational, near-insane, borderline-idiotic stance is irrelevant, and you can see to it that your niece gets the other two shots. Yes? Why even bring the subject up? Let your niece tell her mom if she wants to.

If I were in your shoes, I'd be telling her "If you get these shots, you will never get a certain kind of cancer. If you tell your mom, you might. Sometimes it's OK to lie by omission."
posted by ten pounds of inedita at 2:01 PM on November 23, 2007 [7 favorites]

First thing, the HPV vaccine doesn't prevent ALL cervical cancers. It protects against the strains of HPV that cause 70% of all cervical cancers. Not knocking the vaccine, just trying to make sure the facts are shared.

But anyway, if you have custody of your niece for any reason due to your sister's parenting, I would say you call the shots (no pun intended). You are her legal guardian. I could see being wary if you sister was, say, in the military and you had her daughter for that reason (but I'm pretty sure the military makes you get vaccines).

Your sister should also know that Gardasil is free of mercury, thimerosal or live or dead virus. A lot of people are scared of vaccinating kids because of the mercury in some vaccinations, but Gardasil doesn't have any.

I would not, however, lie to the kid about anything.
posted by fructose at 2:22 PM on November 23, 2007 [1 favorite]

If I were in your shoes, I'd be telling her "If you get these shots, you will never get a certain kind of cancer. If you tell your mom, you might."

To suggest to a child that her mother wants her to get cancer? No. Absolutely not. Leave the child out of this discussion, completely.
posted by ThePinkSuperhero at 2:36 PM on November 23, 2007 [1 favorite]

Seconding the point that you are this child's custodian, and despite your desire to honor your sister's (highly questionable) wishes, you should trust your own and your MD's judgment on this. Also, you mentioned that the child's doctor had recommended "the usual boosters," but if her mother never had her vaccinated in the first place, then (IANAD) she may need more than just the booster doses of the usual childhood-disease vaccines, so you're right to take this up with the doctor as soon as you can.

If your sister is strongly Anti-Vaccine, then she may be very unhappy about and resistant to any reasonable explanation you offer, but the first order of business is to find out from her what vaccines, if any, the child has had, and when -- unless that's already detailed in her medical records -- so that you can decide how to proceed.
posted by FelliniBlank at 2:37 PM on November 23, 2007

To suggest to a child that her mother wants her to get cancer?

I'm having trouble seeing how that could be inferred from what I wrote.
posted by ten pounds of inedita at 2:38 PM on November 23, 2007

You have custody so that, in part, you can make rational decisions about the child's best interests instead of letting your sister's crazy notions cause harm to the child.

I assume you promised to put your niece's best interest first when you agreed to take custody? Then do so, and get the rest of the vaccination.
posted by Justinian at 2:50 PM on November 23, 2007

I got the first HPV shot and asked my doctor what would happen if I never got the other two. She told me that the first shot offers 95% protection, the second shot brings it up to 98%, and the third to 99.6% (I'm not sure how accurate her numbers were, but I follow her concept). After moving and losing insurance and other issues and such, I was not able to get the second or third shots.

You should really call her doctor and ask about this, you don't have to wait for another appointment. That is what doctors' offices are for.
posted by rhapsodie at 2:53 PM on November 23, 2007

If you are the legal guardian, then your responsibility to protect the child's wellbeing to your own best ability and understanding is more important than any other obligation in your life.

Call the doctor's office and explain the situation and your concerns and ask for advice. For instance, if you believe that the birth mother will regain custody and not follow-up with the shots, then the doctor can advise you on whether this could be harmful and what you can do to prevent the harm. They can also help explain to you the pros and cons of vaccination.

Then you can go back to the birth mother and explain that you were doing your best to protect the child and that meant deferring to the advice of the doctor, who has years and years of training and is more knowledgable about the good and bad possibilities than anyone else. If the birth mother doesn't accept that explaination, then they're just out of luck and will have to live with it, because you're doing your best to keep the child healthy, and that is the most important thing to both you and the birth mother.
posted by Skwirl at 2:55 PM on November 23, 2007 [1 favorite]

Leave the child out of this discussion, completely.

Yes, absolutely. This is between you and your sister—and it seems like there's still a lot to sort out, not just about vaccinations but decision-making in general.

As with any custody situation, you can't undermine the non-custodial parent with the child, but you do need to look after the child's best interests. That's your primary duty. In this case, I think that argues for continuing the vaccination series.

You must have a social worker already but I'd encourage you to find a local support group or resource center for custodial relatives. (Many of them started out for grandparents but have expanded to include other relatives.) Grandsplace has listings for each state. The Child Welfare League links might be useful.

This certainly won't be the last time you face a similar situation with your niece and your sister, and you'll get better advice from a group of people more familiar with your situation.

Best wishes to all of you.
posted by dogrose at 2:57 PM on November 23, 2007

I agree with Justinian. You are the one with custody, presumably for a very good reason if her mother is still alive. You shouldn't be annoyed at yourself for your lack of foresight - you're not supposed to be doing things that your sister would approve of, because she clearly approves of the wrong things, or she would be the one with custody.

Parents who don't "believe in" vaccinations are deeply irresponsible. Fist of all, it makes no sense to talk about "believing in" vaccines - they're not God, or the tooth fairy. It's not a matter of belief. It's purely a matter of evidence. Vaccines are safe and effective, and save millions of lives every year. Can you imagine what life would be like if we hadn't invented the smallpox and polio vaccines? Death and misery for millions of children.

Britain is experiencing measles epidemics that have killed children because of irrational hysteria stirred up about the MMR vaccine. It was alleged to cause autism, and despite the fact that that's been thoroughly debunked, and the researcher who alleged it has been shown to have been in a conflict of interest, parents were scared and confused enough to withhold this vaccine from their children.

I don't cut the parents a lot of slack, because when you're talking about the health of your children, you have an obligation to ensure that you're acting on real evidence, not just reacting to something you half-heard on the radio. And parents who refuse vaccines are basically free-riding, hoping that enough other parents expose their children to the (vanishingly small) risk of vaccines in order that there might not be enough non-vaccinated children to spark an outbreak. It's far too easy to forget about the other, larger risk: that enough people behave as you do and your child becomes exposed to the much larger risk associated with these diseases.

Now, at least with the HPV vaccine, there's a lower risk. A lot of people get HPV, many are never symptomatic, and very few actually develop cervical cancer. But so what? There's no way your niece is going to die from this vaccine, and there is a risk that she'll die of cervical cancer if she doesn't get it. Seems like a pretty big no-brainer. And the fact that her mother has no brain shouldn't stop you from doing the right thing.
posted by Dasein at 3:10 PM on November 23, 2007 [1 favorite]

Vaccine efficacy remained high for women who were HPV naïve at the beginning of the trial, but who received fewer than 3 vaccine doses or became infected with a HPV vaccine type during the vaccination course. Efficacies of 99%, 94%, and 94% were demonstrated against HPV 16/18 related CIN grade 2/3 or worse; any HPV6/11/16/18-related CIN (of any grade); and external genital lesions, respectively.
posted by 517 at 5:42 PM on November 23, 2007 [1 favorite]

The HPV vaccine does not contain live virus, so it's *expected* that a single shot will not create an adequate immune response. Looking into the literature on gardasil, even the earliest trials in primates seemed to have been on three shot protocols. Typically, protective antibody levels didn't reach their full levels until after the third shot (which is what you'd expect). The really old animal data looks to be mostly unavailable online. I do not see any human trials using less than all three shots.
posted by a robot made out of meat at 6:34 PM on November 23, 2007

1) Not completing the vaccine series merely lowers the "take rate" of the vaccine in large groups of people. In an individual person, there is no "take rate;" either the vaccine is efficacious in conferring immunity or it isn't. The chances of it being efficacious are higher if you complete all 3 shots.

2) You didn't ask whether the child should be vaccinated, so I won't mention my strong opinion that she should (apart from this pathetic paralepsis.)

3) Although you should properly weigh the child's and the mother's opinion on this matter, the final decision rests with you because you hold custody. My opinion is that, of the three people involved here, your judgment about what is appropriate is most important and you should rely on your own well-researched opinion about what to do, not on anyone else's.
posted by ikkyu2 at 6:42 PM on November 23, 2007

Why tell the mother at all? Yes, she has an opinion, but it's worthless in this case. You'll do your niece a favour if she goes through with the shots. Discuss vaccines with your niece, make sure she understands how they work and why she's having them. Ignorance causes your sister's fears.
posted by stereo at 8:35 PM on November 23, 2007 [1 favorite]

For the benefit of the two people who wondered out loud, there are some people with cultural/religious objections to vaccination. Not a lot of people from a Christian Science background would go for this, for example.

I'm with the they're-reckless-freeloaders group, myself.
posted by genghis at 8:55 PM on November 23, 2007

Fourthing the comment that the two latter injections are a necessity to ensure the efficacy of the vaccine.

I used to promote this vaccine and was personally appalled by the number of physicians who flatly told me that they would not tell their patients about the vaccine or would not allow it to be administered in their office because it would encourage children to be promiscuous.

Totally off topic, but I agree with previous posters- this is an incredible vaccine and information on it needs to be made widely available.
posted by arnicae at 11:38 PM on November 23, 2007

Vaccine uptake might be better if supporters did not misrepresent the benefits. I can trace only one recent news story about a measles death in the UK -- billed as "First measles death for 14 years". And that was a child with an underlying lung condition and, another news story says, a weakened immune system.

Clearly the effects of a single Gardasil vaccination are being misrepresented to some MeFites, as we get two totally different stories showing up in the comments...

I believe the underlying science, I just wish we could get more honest evaluation of the effects.

As far as the OP's moral dilemma is concerned, a lot seems to depend on the details of the custody arrangement and the impact on mother and daughter if they learn of the inadvertent crossing of an invisible line. I imagine it is very important to this child's future that her aunt and mother stay on good terms and I would put that high up the factors influencing what I would do. It is not a death sentence for this child to have the vaccination deferred until she is able to make the decision herself.
posted by Idcoytco at 5:08 AM on November 24, 2007 [1 favorite]

If you are going to have custody of your niece for the foreseeable future, and you are 100% confident that she will not be having unprotected underage sex anytime in the next few years, why not wait until she is old enough to consent to the complete course of vaccination herself? This lets you off the hook with regard to you sister, and you can steer your niece back towards Gardasil when you think she might be ready. If however you think she's at risk of HPV in the near future, I agree with everyone else that you should just get the shots and tell your sister in was strongly recommended by your doctor.
posted by roofus at 6:57 AM on November 24, 2007

Whatever you decide to do, you should also be thinking now about how you plan to let your niece know that she's had this vaccine. That's not necessarily something she needs to know now, particularly if you're worried that she will inadvertently disclose it to her mother and cause a huge rift, but please plan on how you will let her know when she's 18.

This vaccine is covered by insurance up until the age of 25, and so seems like there's a chance that she'll choose to go get herself vaccinated once she's in college or in her first job with decent health insurance. (That has certainly been the case with most of my peers.) I don't know of any evidence that it's harmful to get more than 3 shots a few years apart, but if she gets an abnormal PAP smear or decides to get the vaccine herself, she really should not be in the position of not knowing what her own medical history is so she can make informed medical decisions for herself years down the road.
posted by iminurmefi at 12:19 PM on November 24, 2007

You should finish what you started. Would you feel worse if her mother was mad at you or if the child got HPV?
posted by Mr. Gunn at 5:41 PM on November 24, 2007

ikkyu2, on what do you base your statement of binary all-or-none protection in a given individual?

My understanding is that many vaccinations are given in a series with the idea of 'epitope sharpening' -- the first shot has a high dose of antigen, and selects for T/B lymphocytes that have some (not necessarily high) affinity for the antigen in question.

We then wait an interval and rechallenge with a lower dose of antigen, specifically with the idea of selectively promoting the survival of lymphocytes with higher affinity for the epitopes being vaccinated against. (It is now clear that certain types of memory T cells, at a minimum, may require MHC-peptide stimuli in addition to IL-7 and IL-15 for long-term survival.)

The process can then be repeated with an even lower dose of antigen to further 'sharpen' the response. This model would suggest that administering only part of a vaccination series for a given pathogen may indeed confer partial protection, not all-or-none protection.
posted by NucleophilicAttack at 5:59 PM on November 24, 2007

NA, I take your point. I'm coming from the point of view that a patient is exposed to a given exposure of HPV and either that patient develops symptomatic infection (warts, dysplasia, cancer) or that patient does not develop those. Vaccinated people are less likely to develop infection after the same exposure; completely vaccinated people are even less likely to do so than partially vaccinated people.

Also, although epitope sharpening may be relevant here - I don't know - all three recommended doses of Gardasil are identical.
posted by ikkyu2 at 12:52 AM on November 25, 2007

If anyone's searching on this topic, I've always heard it referred to as 'affinity maturation'. However, there are killed/inactive vaccines offered as single-dose, for example influenza. The HAV vaccine is two-doses. Killed polio is four doses (I think?). Rabies is 3 pre and 5 post exposure. There's a certain amount of empiricism in deciding exactly how many doses are required. You expect the antibody affinity and basal production to keep going up, but exactly what antibody titer that you need is, as far as I know, not known in this case.

Since HPV is a much greater burden on the third world, expect future trials using single-dose regimens. The companies owning the HPV vaccines have no incentive to sponsor them, so they'll probably have to wait until the patents are off, and maybe not even then. I was told that the recombinant yeast and purification of the VLPs is pricey, so the developing world might not be able to afford it even then.
posted by a robot made out of meat at 7:34 PM on November 25, 2007