Are “Alternative Schedules” a Good Idea?

Many parents are leery of a “one size fits all” vaccine schedule and are interested in “alternative” schedules that “spread the vaccines out” over time. One of their main concerns, addressed above, is that too many vaccines in one visit could overwhelm the immune system. They also worry about the potential for serious reactions and the cumulative effects of chemical additives and “toxins” derived from pathogens. Sympathetic voices are easily found.

Alternative schedules are seductive—they reduce the cognitive dissonance between wanting to remain “pro-vaccine” and “pro-protection” and the fear that vaccines are harmful. The problem is that alternative schedules do not provide optimal protection. Moreover, there is no scientific basis for their implementation; in fact, the “basis” for alternative schedules, like so many other antivaccination positions, is anecdotal experience, conjecture (hyperbole), false assumptions, misinterpretation of published data, and a failure to understand the workings of science.

Here are some take-home points:

• Tailor-made schedules violate an implicit social contract. This is perhaps the most egregious aspect of schedules that delay vaccinations. Any given individual has the personal luxury of delaying certain vaccines because the diseases are uncommon. But the diseases are uncommon because the other children are immunized on time. To put it another way, the other children and their families have taken on the personal risk of immunization (eg, sore arms and low-grade fevers) so that all children are protected; in this context, delaying vaccinations in your own child exploits the goodwill of others. What proportion of the population would need to delay vaccinations such that the diseases would come back in force? What if everyone chose to delay?
• Alternative schedules necessitate prioritizing some vaccines over others. None of the vaccines in the routine childhood schedule have priority over the others. This is because the occurrence, by importation or otherwise, of any of these diseases is completely unpredictable.
• Spreading out vaccines requires more visits. The routine childhood schedule accomplishes series completion in 4 or 5 visits by 15 or 18 months of age. Some alternative schedules require as many as 15 visits to accomplish the same goal, with series completion delayed until 42 months of age. At a time when health care costs are under scrutiny, it seems wrong to spend money on unnecessary visits. In addition, the more scheduled visits there are, the more visits that will be missed, leading to further delays and costs.
• Delaying vaccines creates risk without benefit. Here’s an example. Some advocate delaying the birth dose of HepB until the third year of life. As we learned in 1999, when hospitals deferred the birth dose because of the thimerosal scare, this practice will inevitably result in some infants who should have been protected by vaccination but were not (the issue is that many women have unknown HBsAg status at delivery, and even when the maternal record says “HBsAg-negative,” that might not be true). Given the safety and immunogenicity of the birth dose of HepB, there is no benefit to delay. Likewise, given the safety and efficacy of all routine vaccines, the only accomplishment of delayed vaccination is susceptibility to the diseases, which are still out there. In fact, a study published in 2010 showed no adverse effect of on-time infant vaccination on long-term neurophysiological outcome.

—Marshall, Gary S. “Addressing Concerns About Vaccines.” The Vaccine Handbook: A Practical Guide for Clinicians. 3rd ed. New York: Professional Communications, Inc., 2010. 214. Print.

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