1. Kevin Smith, Erin Brogden, Shatarius McGhee

2.  C.C. has an 11-year-old child with high functioning autism. She is pregnant with her second child and tells her best friend (a pediatric nurse) that she is considering not allowing her second child to receive immunizations as she believes her first child’s autism was caused by the immunizations. C.C. asks for your opinion regarding her decision (Case Study 9).

3.  Studies have reported that autism may be caused by a substance known as thimerosal.  The statistics show a need for concern and the need for studies on a possible correlation between the administration of immunizations and autism.

4.  The goal of the query is to determine whether immunizations cause autism in children ranging from one month to six years of age.  Do childhood immunizations contribute to the prevalence of autism in children between the ages of one month to six years?

5.  PubMed and CDC were the chosen resources to search for the best available evidence to answer our focused question  PubMed is a government database that provided necessary research evidence for our search, such as the effects of childhood immunizations on autism.  The CDC is also a government site that provided accurate information about immunizations in relation to autism.

7.  To provide an answer for the focus question, information related to childhood immunizations and autism in children ranging from one month to six years of age was the main point of the search.  Conducting a search within PubMed and Center for Disease Control and Prevention with the specific words such as childhood immunizations, autism, and thimerosal allowed for more closely related information to answer the focus question.

8.  Problem - We identified our problem as “Do immunizations cause autism?”.  Patient - Our patient is a pregnant woman who already has an 11-year-old autistic child.  Action - We are taking action by providing our patient with education on immunization benefits for children. There is no alternative action.

9.  Patient Results - The result of our research came from Centers for Disease Control and Prevention, which showed there is no correlation between immunizations and autism (Vaccine Safety 2013).  Level of Evidence - We used the highest level of evidence available to draw our conclusions, which were meta-analyses, systematic reviews and evidence based reviews.

10. PPAARE ComponentCase Example Problem Do immunizations cause autism Patient A woman who is pregnant with her second child and has an 11 year old autistic child Action Patient education on immunization benefits for child Alternative N/A Patient Results According to CDC there is no correlation between immunization and autism Level of Evidence Highest available – meta-analyses systematic reviews, evidence based reviews

11.  The articles that were found within PubMed and the Centers for Disease Control and Prevention were relevant to our focused question because of the information about vaccines in relation to autism.

12.  The first article in the table is “Autism Spectrum Disorder” which focused on the number of children diagnosed with autism in 2013 (2013).  The second article in the table is “prenatal and infant exposure to thimerosal from vaccines and immunoglobins and risk of autism “ which was a randomized controlled case study (2010).  Then third article from CDC titled “Vaccine Safety” provided detailed information about thimerosal and how it affects vaccinated children (2013).

14.  A series of formulated questions were used to determine the trustworthiness of the quantitative study.

16.  A series of formulated questions were used to determine the trustworthiness of the qualitative study.

17. CONTENTQUESTIONSAPPRAISAL\check one box Author’s names, credentials, affiliations, and conflict of interest M Evans, BA (Hons), MA, research associate; and H Stoddart, MD,MRCGP, MFPHM, clinical lecturer, Division of Primary Health Care,University of Bristol. L Condon, BA (Hons), RHV, R Mullen, BSc, RHV,health visitors, United Bristol Health Care Trust. E Freeman, MPhilBEd (Hons), RHV, primary care research co-ordinator, Gloucestershire Research and Development Support Unit, Gloucestershire Health Authority. M Grizzell, PG Dip HP, RHV, lead health visitor, Frenchay Health Trust. 1.Are the authors’ credentials and educational background appropriate to conduct this type of study? Yes, the authors have their degrees and affiliations within the healthcare field and also a MD is involved in the study who meets the requirements to lead the study. 1.Are the authors affiliated with an educational program, health institution, or practice setting? Do the authors report a conflict of interest? Some of the authors were affiliated with the health institution and some with the practice setting. __x__Strength _____Limitation _____Not evident _____Not applicable Funding source(s) Does the funding source have a vested interest in a beneficial outcome of the study? The Study was funded by a research grant from the NHS Executive South West Regional R & D Directors, to promote research. ___x__Strength _____Limitation _____Not evident _____Not applicable

18.  The main course of action would be patient education on whether childhood immunizations contribute to the prevalence of autism in children between the ages of one month to six years.  The best way to implement patient teaching is by providing videos, pamphlets, brochures, and appropriate verbal teaching to the patient.

20.  Following patient teaching about autism and immunizations C.C. decided to allow her second child to receive the immunizations.  The client’s child was later evaluated and tested for autism. After testing the client’s child it was determined that her second child had no signs of autism.

21.  According to the research C.C. was informed that it is in the best interest of her child to allow him/her to receive immunizations.  The research information helped determine that thimerosal, which is the questionable substance in vaccines, is not linked to autism (Vaccine Safety 2013).  The research primarily came from Centers for Disease Control and Prevention and additional research articles obtained through PubMeb, which showed there is no correlation between immunizations and autism (Vaccine Safety 2013).

23.  http://www.youtube.com/watch?v=qGW4a96 GqGc http://www.youtube.com/watch?v=qGW4a96 GqGc  http://hollywoodlife.com/2010/02/26/jenny- mccarthy-says-her-son-evan-never-had- autism/ http://hollywoodlife.com/2010/02/26/jenny- mccarthy-says-her-son-evan-never-had- autism/  http://www.youtube.com/watch?v=UcktuOQ zd9g http://www.youtube.com/watch?v=UcktuOQ zd9g

24. Autism spectrum disorders. (2013). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/ncbddd/autism/data. html CDC study on prenatal and infant exposure to thimerosal from vaccines and immunoglobins and risk of autism. (2011). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/vaccinesafety/Concerns/ Thimerosal/QA_Pediatrics- thimerosal- autism.html

25. Evans M., Stoddart H., Condon L., Freeman E., Grizzell., Mullen R., (2001). Parents perspectives on the MMR immunization: a focus group study. The British Journal of General Practice. 51 ( 472 ), 904-910. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1314147/pdf/11761204.p df

26. Jon B., (2008). Prevalence of autism spectrum disorders – autism and developmental disabilities monitoring network, 14 sites, united states, 2008. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/mmwr/preview/mm wrhtml/ss6103a1.htm?s_cid=ss6103a1_w

27. Price C. S., Thompson W. W., Goodson B., Weintrub E. S., Croen L. A., Hinrichsen V. L., Marcy. M.,... DeStefano F., (2010). Prenatal and infant exposure to thimerosal from vaccines and immunoglobulins and risk of autism. Pediatrics official journal of the American Academy of Pediatrics. doi:10.1542/ped.2010-0309

28.  Vaccine safety. (2013). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/vaccinesafety/concer ns/autism/