Reawakening the Protectors.

Columbus, OH, December 2022 I began the long walk over to the extra airborne isolation room in the far corner of the emergency department (ED). This part of the department was now under the supervision of inpatient providers caring for boarding intensive care unit patients transported from all over the state, from hospitals without staff or equipment to care for critically ill children. These were the “stably unstable” patients. My focus for the shift was supposed to be the unstable children flooding the lobby and critical care rooms in the main side of the ED at an unsustainable rate. Despite this, I dutifully walked over to the new patient roomed in the far corner of the department. Shifts like this were often characterized by sympathetic overstimulation, so I used the long walk to take some deep breaths to calm my mind and body. Outside the room, I deftly donned airborne isolation personal protective equipment, as the sign posted on the door instructed me to do, experienced in the motions after almost 3 years of donning and doffing during the coronavirus disease 2019 (COVID-19) pandemic. I entered the room to find mom and baby—10 months old. Mom's exhaustion showed. She had dark circles under her eyes. Her eyelids slightly drooped as though they were heavy from the load of many evenings awake with an ill infant. Despite this, she greeted me with a shy smile and shared her concerns about her baby. The lights in the room were dimmed, likely the bedside nurse's attempt to calm a fussy baby and create a calm environment to allow mom to relax as they awaited my arrival. I winced as I destroyed this transient peace and flicked the lights on to begin a physical exam. The rash that I knew only from textbook images came to life as the room illuminated more completely; her once clear skin was speckled from scalp to ankles with a burgundy exanthem that I had been taught to associate with virulence. The infant looked at me suspiciously as I approached, but her dehydration and illness had progressed to the point that she did not have the energy to protest allowing me to swiftly proceed through the examination. This was a saddening and a telltale sign of a truly ill infant; she was depleted of the vigor to wail at the sign of a stranger. My patient shared a home with her parents and 4 siblings, all fortunately older and fully immunized against measles. Her exposure: likely a busy doctor's office waiting room where she awaited evaluation for a respiratory virus 2 weeks prior to this visit. In that moment, I ached. I was overcome by her vulnerability and the preventability of the circumstance; mom shared that her other children were vaccinated, and that she had tried a slew of supportive care measures before ultimately needing to bring her daughter in. I ached because I knew we could do better and could have prevented this adorable infant from hospitalization. I ached because we needed to hospitalize nearly half of the kids affected in the December 2022 outbreak in Columbus, Ohio. The children affected have primarily been under 5 years old and unvaccinated or incompletely vaccinated either due to age or parental preference. The outbreak once again reveals the alarming lack of herd immunity against an illness that could be eradicated. It underscores the dichotomy I see day to day. On one side, there are caregivers clamoring for their child to receive new vaccines, still under investigation by the Food and Drug Administration (FDA), as soon as possible. On the other, families confidently report that their children are unvaccinated in a way that suggests they believe this makes their child safer and more wholesome. I wondered how the COVID-19 pandemic led to this moment. Did the combination of COVID-19’s relatively mild illness profile in most children, the politicization of vaccine mandates and shuttered primary care offices unable to keep children on vaccine schedules spur more parents to reject vaccination for their children? Without regular, face-to-face interactions with their pediatricians were important vaccine counseling opportunities missed? After seeing this infant suffering from measles firsthand even I, a pediatrician, was reminded of its high transmissibility and severity—hospitalizing 20% of children affected; if I needed this unwelcome reminder, what did nonmedically trained parents need to motivate them to vaccinate their children? After completing the physical exam, discussing the need for admission and next steps with mom, I began the walk back to the main side of the ED. Still saddened by my patient's need for admission for a vaccine-preventable illness, I thought about how I might approach caregivers of kids unvaccinated by choice in future encounters. What could I say? As an ED physician, my encounters with families are brief, often overshadowed by the fear and uncertainty of acute illness or injury and there is limited time to establish rapport with caregivers. As a result, I try my hardest to withhold judgment of caregivers when they disclose that their children are unvaccinated by choice. This admittedly often results in saying nothing. My patient's defenseless, dehydrated body impels me to do more, to say more. It reminds me of our responsibility to be stewards of science and protectors of the health of the most vulnerable.