Tag Archives: Vaccines

Vaccine opposers lack any evidence

This is important: Dorit Reiss on vaccine misinformation in the Point Reyes Light.  The anti-vaccine crowd is vicious, rabid and unfortunately very poorly informed. Yet they have been able to get the attention of enough media to cast doubt on the effectiveness and safety of the most important medical intervention ever devised.

When the only argument against requiring vaccines for school relies on mistaken beliefs about vaccine safety, it cannot stand. Vaccines are safe, effective and save lives. Immunization mandates make our schools safe. By shoring up California’s mandate, S.B.277 is helping to safely protect our kids and our communities.

Measles and the Upcoming Outbreak

The following article was published April 2, 2014 as a guest editorial in the Oregonian and can be found on Oregon Live here. Today, we can say the North American measles epidemic is in full swing. We are just waiting for the body count, a comment the Oregonian in their wisdom elected to remove from my submitted draft. 

 

Measles is near. Last Aug.18, Texas health officials announced 12 cases of measles in that state. By Aug. 20, the number of officially reported cases was 16. The majority belonged to a single church whose pastor had been recommending that parents avoid vaccines. It wasn’t even the biggest outbreak last year. There were 58 cases in New York. So far this year, we’ve had five cases near San Francisco, 20 in Orange County and over 320 cases in Canada’s Fraser Valley to our north, which has spread to at least one resident of Whatcom County Washington. We’ve also had an outbreak of mumps at Ohio State.

It is only a matter of time before the most vulnerable start suffering the consequences of an American epidemic. Oregon is the state with highest exemption rate in the US. This makes our local area particularly vulnerable to an explosive epidemic. Just for perspective, only 3 percent of children are exempted in California, and they have had the biggest outbreak so far this year. As the ring gets tighter, it is only a matter of time before officials in the Portland metro area have to scramble to respond to a disease we thought we had eliminated from our shores in 2000.

Measles is not the flu. It is much worse. Influenza has an attack rate of about 50 percent, measles 90 percent. That means that 90 percent of non-immune people who come in contact with the measles virus will actually acquire the disease. Complications range from the trivial, like ear infections and diarrhea, to dehydration, to pneumonia, dehydration and encephalitis, a serious type of brain infection.

Traditional epidemiology reports that 20 percent of children can expect to be hospitalized, and three out of a 1,000 will die. Most recent data from Europe would suggest that the numbers are closer to 30 percent hospitalized and a 1-2 percent fatality rate.

In the 1950s and 1960s,  an average of 450 American deaths were annually attributed to measles or its complications. Following the introduction of the measles vaccine, the number of cases steadily declined until 2000, when there were no cases at all.  In 2013, the latest year for which the CDC has reported statistics, there were 189 cases of measles.  Many were imported from countries with inadequate vaccine coverage, but we are seeing more cases in vaccine refusers. There have been no recent deaths, but in a large epidemic, the odds are not promising.

After 15 years of misinformation, complacency due to the lack of domestic deaths and a series of paranoid and ignorant conspiracy theories, we are starting to see outbreaks. This is misinformation with a body count.

When the percentage of people immune to measles drops significantly, massive and sudden increases in the number of measles cases follow. In France, where the anti-vaccine movement caught fire in the middle of the last decade, cases of measles went from about 30 in 2005 to 15,000 in 2011. There were six deaths. Last year, the United Kingdom suffered 1,219 cases with one death.

Some of the cases are occurring among children who have received the vaccine. Since vaccines are never 100 percent effective in preventing any disease, the risk of failure rises proportionately to the cumulative weight of exposure. The more cases are in your neighborhood, the greater the chance that your vaccinated child may get the disease.

No vaccine is entirely safe. Balancing the risks of preventing disease with the risks of the actual vaccine is not an easy task. Informed consent is a cornerstone of any medical practice, and every parent has the responsibility of weighing the evidence for themselves. But how do parents decide when the information about vaccines is more about conspiracies and wrong data? How do responsible and critical thinking parents who chose the vaccine react when a significant proportion of their neighbors undermine collective efforts to keep a deadly disease out of their home?

 

Some goals, like eliminating measles, can only be accomplished by group action, taken with full knowledge that a few will suffer, but the majority will gain something significant. This is what it means to live in a community. This is what it means to be responsible.

Cost effectiveness of well child visits

We published this back in 2008 on the old blog. It remains germane to the economics of primary care and I updated it with a link to The Incidental Economist.

 

Immunizations are simply the best and most cost-effective intervention ever conceived by the science of medicine. They are so important that health care providers have toyed with various techniques to improve immunization rates. For example, my current facility has a full-time immunization nurse who can give missing vaccines to children following a sick visit (as long as they don’t have a fever.)

The principle of vaccinating when you got ’em in the clinic is common in many developing countries and under-served areas, since you never know when you will see these children again.

Now the practice is being questioned. According to an article in Pediatrics, some parents don’t bring their children back for well visits. The well-child visit includes a brief developmental assessment, physical examination and anticipatory guidance. These aspects of the visit have great value, especially for the young, low-income mothers who are the most likely to conflate a well visit with a shot.

As a clinician, I understand the value of well child visits, but my public health degree must question the data. There is insufficient evidence to support annual adult examinations. Studies with children are naturally more likely to yield a benefit, but I just haven’t seen them. After all the well-child visit schedule is tied to… you guessed it, immunizations.

It’s good to know that there is documentation of the downside of opportunistic immunization (which has been our experience). I am not sure it matters in the big picture. After all, one of the few things on which health economists agree is that prevention usually doesn’t pay off.

Vaccinate, Support Local & Subscribe

Our clinic, Lacamas Medical Group, runs a couple of free immunization clinic for kids in Camas and Washougal who could not ordinarily pay for their pre-school physicals and vaccines. The Camas-Washougal Post Record, supports us in this endeavor, once running a free ad and this year sending a reporter. This is a link to her story on the web, but they held back a significant chunk for the print edition i wish it had all been online, but I understand why they do that.

I think this may convince me to subscribe. It is a very good publication by the standards of a local weekly newspaper. Moreover it is local, with local news and full of information about local businesses. We can complain about the lack of ethics in corporate America all we want, but without supporting local business, like the Post Record and the businesses that advertise in it, all is for nought.

Vaccine Objector Backlash


In March, a version of the following article appeared in Lacamas Magazine, a local lifestyle publication. It was very well received, and attracted an enormous number of hits. I need to rework something for the local daily paper, The Columbian. Until then, I offer you an opportunity to review and comment; it is a controversial topic but I believe science is the benchmark, not conspiracy theories. We are one epidemic away from the ostracization of people who object to vaccines. This is why my original title is somewhat inflammatory. It was softened for the actual publication.  



Many of the digital back-issues are online, but not the one containing this article. I will link to it if it comes back live.

Vaccines are the most effective tool of medical science to decreasing the burden of human disease since Edward Jenner in 1798 described a method of inoculating healthy people with cowpox to prevent smallpox. Countless lives have been saved worldwide with a record of remarkable safety and a miniscule degree of adverse reactions given the magnitude of the benefit. Despite the incontrovertible weight of the evidence, there remains an anti-vaccine movement and a persistent fear of immunizations of all sorts.[1]

Opposition to vaccines can be found as far back as 1905 when the case of Jacobson v Massachusets went to the Supreme Court. In that case, a father refused to be forced by the state to vaccinate his daughter in the midst of a smallpox epidemic. The Supreme Court found that despite a legitimate libertarian argument, there was a compelling reason to over-ride the rights of the individual when fighting an epidemic because there was direct link between the number of people who were immunized and the total spread of the epidemic. It turns out that interrupting transmission was a function of reducing the number of people who could transmit the virus. The benefit to the person was magnified when the effect on the community was examined.

More recently opposition started with Andrew Wakefield, an English surgeon, who became interested in vaccines and published a study that claimed to show a link between MMR (measles, mumps and rubella) and autism in 1996. Understandably, this captured the imagination of parents everywhere. Can anyone imagine causing brain damage to their children by accepting an injection which was supposed to protect them against a deadly disease? Emotions run high with autism; parents wonder if they did something wrong and grasp at any potential cause to explain he unexplainable.

There were problems with the hypothesis from the start. First, the assertion of a link between immunizations and autism rested on the observation that the increase in the occurrence of autism ran parallel to the increase in vaccinations. Of course many other things also increased in the same interval; there was also an increase in the number of doctors available who could diagnose autism and better diagnostic criteria to distinguish autism from other forms of developmental problems. One can make an argument that anything else that increased over the prior several decades was linked, but a link is not a cause. The number of cars on the road has also increased parallel to the increase in autism, and the lead in automobile emissions is actually biologically active when ingested in the form of dust by an infant. It is more plausible than mercury as a cause, but nobody would take the idea seriously.

The vaccine link was supposed to be thimerosal, a mercury-containing preservative in the MMR vaccine. Mercury is indeed neurotoxic, but not all forms of mercury are active when absorbed into the body. For example, it is the fumes that are the best absorbed and the most active. Inorganic mercury is found almost universally in the soil and water in nature and poses no hazard. Theoretically, someone could swallow elemental mercury and not suffer any effects, because it cannot be absorbed that way (of course fumes may be released before, during or after digestion, so no one will say swallowing mercury is safe.) The mercury in thimerosal is very tightly bound and probably inert. The same way, mercury in the soil behind dams cannot be released into the food chain until bacteria convert it into a form that can be absorbed by eating fish. But mercury in fish is a well-recognized problem and there is no connection between autism and ingesting mercury-containing fish. It is difficult to think about how a relatively inert form of mercury can have any biological activity when injected. In fact, it was found that babies excrete thimerosal much faster than would be expected from our knowledge of how the body handles the toxic forms of mercury. This is one more small piece of evidence suggesting that mercury in thimerosal does not have time to interact with tissue. Nonetheless fear and controversy won out and vaccine manufacturers responded to the concerns. Thimerosal was never universally present in all vaccines and has since been removed in most every vaccine available today, except where it is impossible to use something else for technical reasons. Rates of autism continue to increase.

Then Wakefield’s study blew up! The co-authors smelled something fishy in the results especially when information emerged that proper methods in conducting the study were not followed. Eventually, it became clear that the data had been falsified, Wakefield was accused of fraud and he lost his license to practice medicine. It is believed that he falsified data so that he could profit from being a consultant on all the lawsuits that would follow. He currently lives in Texas.

The damage he caused was in stirring up a controversy that was not based in any sort of fact, in spreading false information and fear leading people to refuse vaccination and suffer the burden of increased vaccine-preventable disease making a come-back, in intense efforts to remediate a problem that did not exist and untold research dollars that would have been better spent seeking the real cause of autism. We can see the traces of his misinformation when someone like Congresswoman Michelle Bachman says that she knows people who got autism from the HPV vaccine. The statement is appallingly ignorant, brutally stupid and horribly violent for the children who would benefit from the vaccine.

Some people seem to feel that the number of vaccines is an overwhelming assault on the immune system. The problem with this notion is that in each vaccine there are a handful of highly purified proteins designed to arouse a strong immune response. Purification may always introduce trace chemicals, but at levels less than the neighborhood pool. A bowl of chicken soup probably contains an order of magnitude greater number of proteins that the entire set of childhood vaccines from birth to the teen years. It seems much more likely that prematurely feeding an infant adult food would be more harmful.

The number of needles required frequently comes up with parents. It is easy to understand how five injections at one time can be heartbreaking, especially as the child begins to wail. Older doctors however remember the days that circumcisions were done on infants without anesthesia. Without condoning what seems like a barbaric procedure to some, there is some dissonance between insisting on a circumcision on one hand and worrying about an extra needle on the other. The pain is limited. The benefit is huge.

The immunization regimens are constantly being revised and changed as circumstances permit, including the increasing availability of combination vaccines to reduce the number of individual injections. We must also remember that vaccines have become victims of their own success. When polio is fresh in people’s memory — the paralysis, death and suffering wrought by a horrible disease — it is easy to convince parents that the vaccine is necessary. When the disease has become rare because of the widespread use of a vaccine, the benefit does not seem as significant. Until the disease starts coming back, that is.

Other accusations thrown around about vaccines are that they represent a conspiracy on the part of pharmaceutical companies. This is laughable to people who have been interested in vaccines since the decades that research had stalled. In the 80’s, fear of litigation led most manufacturers to withdraw from vaccine research and development and shortages were looming. In 1986 Congress created the National Vaccine Injury Compensation Fund so that people who were injured by vaccines could be compensated publicly  After all, there is a societal good to vaccination that makes even the rarest adverse reaction doubly tragic. Two things happened after establishing the fund; first vaccine manufacturers reinvested in developing vaccines and lawsuits plummeted. It seems the new fund was more rigorous in making awards, not subject to the vagaries of the “jury lottery” of super-sized awards and nuisance claims. In other words, vaccines do not have a history of being particularly profitable, at least until the past couple of years when prices have started to sky-rocket. In the mean-time the compensation fund is one government program that is significantly over-funded because there have been so few claims made.

Incidentally, the body that makes vaccine recommendations is the American Committee on Immunization Practices, set up by the CDC at arm’s length. It has representation from numerous medical, public health and consumer groups and has remained stubbornly independent. It accepts no money from industry, works only peripherally with the FDA, limiting its recommendations to FDA approved parameters and constantly weighs the risks and benefits of any immunization. All their deliberations are public, transparent and available online. With the National Science Foundation and The Institute of Medicine, the ACIP is one organization that is least likely to be swayed by the big pharma’s financial interests.

Clark County’s Public Health Officer Alan Melnick is fond of saying that “vaccines prevent diseases that kill kids.” This is also true for adults. The ACIP makes recommendations based on the best science and evidence available with the aim of saving as many lives as possible with the lowest risk of any adverse events. The science and the evidence demonstrate that there is a community benefit that exceeds just the individual protection. Diseases like whooping cough and measles can still occur in an immunized population if enough people remain uncovered. It is not enough to immunize your own kids if neighbors and schoolmates refuse their immunizations; your kids can still get sick. The risk is small but probably greater than the risk of a serious reaction to a vaccine. It is an inflammatory statement that may yet prove true; that not immunizing your own kids can allow diseases to spread that potentially can kill other kids as well as your own. Vaccine objectors have not yet faced this backlash, but it remains that human beings living in communities have a responsibility first to themselves and their families, but then also to the communities which sustain them.



[1] An immunization is an intervention designed to increase an immune response to a specific agent. Vaccines have come mean the same thing although historically the word vaccine refers to vaccinia, the cowpox virus used to prevent smallpox.