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Wednesday, November 27, 2013

Vaccination: A Layperson's Perspective

From Married to Medicine

By Lisa Murakami
September 26, 2013

Needles:  Scary. 
No medication, not even Tylenol, is
100% safe or side-effect free. 
Neither is highway driving, for that matter. But
vaccines are a thousand times safer than driving.  

As a medical "layperson," it's ironic that I'm blogging about vaccination - or at least I think it is.

While my husband slaved away on all the pre-med courses in college, I avoided science like the plague (terrible pun, I know.). When he scored within the top 2% of MCAT takers I was pretty impressed, but truthfully I don't know much about the MCAT. While he busted his butt - to put it politely - through four years of medical school and two years of grant-funded medical research, I studied the health care system... in law school. And over the past 4.5 years that he's been putting in 60-100 hour weeks in medical training at the #1 hospital in the U.S., I've thankfully managed to continue to ... not study or practice any medicine.

That means that he has 14.5 years of grueling medical training that I don't have. And - conservatively estimated - 28,160 hours. My father has infinitely more; he's seen tens of thousands of patients over the course of his forty-year career as a pediatrician.

Clearly, I can't run a google search on a complex medical topic and eventually cobble together a better answer on it than these two can. Not even if I spent ten hours on it. Not even if I spent forty. Not even if I spent weeks. They don't hand out medical degrees for running google searches. Or for talking to midwives... or doulas... or anybody else. Imagine if they did though, and you got in a car accident or you had a heart attack, or you needed a liver transplant or something. Um... yikes.

But the problem is that lay people are blogging about vaccination. And they're meeting up and talking about "vaccine choice." They're imagining conspiracy theories and refusing to trust anyone other than each other. And they've managed to convince others of their "practice of medicine" to the point where there are schools at which only about half of the children are vaccinated and many states are falling below vaccination levels considered to provide herd immunity.

"Herd immunity" is real and it protects us all, especially those who are too young to receive their first vaccines or who are immunocompromised because of a childhood illness like cancer (see the comments for further discussions on this). Herd immunity even protects the vaccinated, as vaccines are "only" 90+% effective, not 100%. Herd immunity is the reason we're not currently in this situation (or this one, or countless others). Would anti-vaxxers still refuse vaccines if they had to travel to one of those nations? And if not, are they only refusing them here since the rest of us do vaccinate?

This topic is so vast and so complex that I'm not going to pretend to be able to address it in single coherent blog entry (unlike so many anti-vaxxers). But I do want to put together a bullet-pointed list of what I, as a layperson with personal access to the medical community, believe that you, as a layperson without that same access (clearly - if you're considering not vaccinating) might want to know. I've followed and participated in many discussions on this topic and there are some repeat misconceptions or missed points that are worth cobbling together.

Here are a few of them:

1.) Vaccines do not cause autism. See also this, this, this, this, this and this. Kudos to Dr. Andrew Wakefield for getting published in a legitimate medical journal, since everything else on this topic either wasn't, or has been misleadingly taken out of context and interpreted by non-medical minds to mean something it doesn't mean to any other physicians, who are also parents themselves.

Too bad though - after other labs were unable to get any results by repeating his study, and after he was unable to reproduce the results himself, the original study was found to have fraudulently falsified its data (this "caught ya!" process is called peer review, and it's why we can rely on science). He made millions and children died. Not sure what that makes him in your book, and I don't want to mention what that makes him in mine. Maybe we should honor those deaths... by vaccinating.

Here's some more persuasion though, if that's not enough:

We've been vaccinating since the 1950s, so we vaccinated for many decades before autism rates went up. The spike has been most significant over the past five years, in spite of the decline in vaccination rates. Hmm. Doesn't seem that vaccines are the cause, does it?

Maybe you know or have heard about someone who went from "normal" to autistic right after his shots. Well, autism is an early-childhood onset condition, and it happens that we vaccinate early in childhood. There are lots of children out there whose symptoms started shortly BEFORE their shots, too; they're just not organizing themselves and speaking out about their experiences. Anecdotal evidence, while compelling to those personally experiencing it, does not show or prove correlation (let alone causation). Medical studies do, but they have repeatedly disproven that vaccines have any relation to autism - every single legitimate, peer-reviewed study (see the links above).

If that weren't true, and this was, then your pediatrician wouldn't be vaccinating his or her own children - at rates even *higher* than the official recommendations.

Okay okay, you still can't be convinced, and perhaps you would like to speak at the next national AAP conference on this topic, and present to them the articles you found on the internet. Well how about the point that my friend made? Her brother is autistic. She loves him just the way he is, and would much rather an autistic brother than a dead one; she takes more than a little offense when people don't vaccinate for fear of autism. I'd rather an autistic child than a dead one myself, personally. But thankfully, we don't have to choose ... because vaccines do not cause autism!

Watching your baby struggle with or
die of suffocation by whooping cough:
Much, MUCH Scarier.
Did you know that kids who miss doses of their
DTaP vaccine are 18x as likely to get it

2.) On "alternative schedules." Some people acknowledge that vaccines don't cause autism, but remain convinced that all those pediatricians out there who are vaccinating their children "on time" - meaning, on the schedule created and monitored by the AAP and the CDC, among other professional organizations - are sadly mistaken. They believe there is a "true" best vaccine schedule out there but that pediatricians aren't recommending it - or using it on their own children - because:

(a) it's more convenient for doctors to lump the shots together; or,

(b) the U.K. gives fewer vaccines so the U.S. must be "shot-happy" since we're "for-profit"; or

(c) they read one book by one physician, Dr. Sears, the "schedule" in which has been completely discredited (see also this, this and this for further confirmation of the safety of the current schedule); or

(d) they think we are vaccinating too early because we want to get kids vaccinated before irresponsible parents stop bringing their children to medical checkups.

Well, (a) and (b) cannot possibly both be true, since more visits means more money. So pick just one first, please.

(a) is not true. Doctors wouldn't care if people came in a few more times to get shots; what's it to them? And again, they vaccinate their own children on the AAP/CDC recommended schedule. It's actually more convenient for your child to be poked less with a needle.

But none of this is about convenience; vaccines are simply given as early as they can be, because the sooner a baby is vaccinated, the sooner he or she is safe. Just last winter a baby boy at Boston Children's contracted whooping cough from an unvaccinated toddler. He died - just days away from his first vaccination. So did this child, and many others. Pediatricians are now advising parents on how best to protect their newborns, until their babies are vaccine-eligible

(b) varies by vaccine and is far too complex for this blog entry. Suffice it to say that the U.K. is a different country with a different population, and if our vaccines weren't medically necessary, our insurance companies would be the first to let us know by not covering them. You can also check out this story about a mom in the UK whose daughter died of chicken pox, not having been vaccinated since the chicken pox vaccine (Varicella) isn't on on their vaxx schedule.

(c) why are you trusting someone with whom no other expert agrees, and who is making millions off of this, instead of your own moderately-salaried pediatrician(s)? Okay I get it - you've had a crappy doctor (or doctors) before. Me too. Not everyone is willing to bust their butt like my husband does. But this debate isn't pediatrician-to-pediatrician. This debate involves a clear, essentially unanimous medical consensus among all our leading experts.

See, also cited above, this, this, and this. When you vaccinate on time, you're not "just" trusting your pedi; you're trusting all the top experts on topics including virology, microbiology, statistics, epidemiology, pathogenesis ... and of course, medicine and pediatrics. We're talking the guys who went to Harvard and the like, and got M.D.'s and Ph.D.'s and devoted their careers to research, which generally pays much less than private practice. These tend to be, FYI, super nice and super nerdy guys (and gals) - and most of them are also parents.

They make up the AAP and the CDC and other organizations that put their heads together and come out with the schedule. I truly hope that you don't think that you or I could come up with a better answer than they have, by Googling or by doing other layperson "research."

See also this article - delaying vaccines can increase your chance of having a reaction because your body is better able to mount a stronger immune response; see this, too, for a further discussion. See also this video on the dangers of under-vaccination - children who skip doses of their DTaP vaccine are 18x as likely to get whooping cough.

(d) We aren't vaccinating earlier than "we should" just because some parents might "flake out" on later appointments; we're vaccinating as early as possible because unvaccinated newborns are unprotected and they could, and do, catch things like whooping cough in hospitals and at checkups (and from relatives and friends - especially those who haven't had their boosters) and die. Do you really think that the CDC, AAP, etc., came out with a "truly ideal" schedule, but are keeping it secret because of flakey parents? If so, why do you think that all these physicians and experts follow the recommended schedule on their own children? Again, pediatricians are now advising parents on how to protect their newborns until they are vaccine-eligible.

What about Hep B, they give that one at birth, why?? That's because the Hep B vaccine also protects against "vertical" transmission, meaning transmission from the mother (or father ... or father to mother to child), which usually (but not always) occurs perinatally (meaning at birth).

Because there's no risk in giving this vaccine at birth (none proven, other than the mildest of reactions for this vaccine - see discussion in comments below and what I quote from UpToDate, and ignore what you read on non-reputable websites), and because doing so for the entire population will prevent cases of this terrible disease (and probably eventually eradicate it), that's standard procedure.

Studies on this topic have shown that prenatal maternal testing is not a good way of preventing or predicting perinatal transmission, or childhood acquisition of unknown origin - this is discussed in greater detail in the comments following the post.

NPR article from 9/30/2013: Study confirms that
a recent whooping cough epidemic in California
that killed ten babies was due to failure to
vaccinate and receive boosters.

People who lived in areas with high
"personal belief exemptions" from public school
vaccination requirements were 2.5 times as likely
to live in areas with high incidents of whooping cough.
Link to original study appearing in Pediatrics.

3.) Won't breastfeeding offer the same or better protection? No. How would there have been polio epidemics in the early 1900s if that were true? Polio (as one example) was eradicated in the 1950s when we started vaccinating for it. People actually nursed less in the 1950s than they do now; nursing fell out of favor when commercially marketed formula was presented as and believed to be "better" than breastmilk. My mother-in-law was breastfed, but she still remembers how horribly sick she was with the measles.

4.) What if you keep your kids largely at home with you, should you still vaccinate? Yes. You and your children could end up in a medical waiting room at any time, and that's where the sick kids will also be. See the story above, about the boy who died last year here in Boston. Plus, even if you home school, your kids will be at museums and basically, in public. These diseases are highly contagious. You don't have to share a toy or even a doorknob to catch them.

5.) But my pediatrician approved my proposed alternate schedule. Ask your pediatrician: How would he or she vaccinate his own children? That's the truth of the matter. Delaying a vaccine leaves you vulnerable until you take it, while offering no proven benefit whatsoever. It's a small chance, but it's getting bigger as we've seen in the news lately. Skipping doses is even worse - again, see this video on the dangers of under-vaccination - skipping a DTaP dose makes your child eighteen times more likely to get whooping cough.

6.) But what if it's just a hoax that vaccines are even effective at all? I mean why else would vaccinated people care whether I vaccinate? If you really believe that all our nation's pediatricians and scientists, and those of all the other nations too, and all the legitimate peer-reviewed medical studies, and every history textbook you can get your hands on are all mistaken, there might just be no hope for you.

But in case your common sense can be appealed to, the answer is that vaccines are not 100% (more like 90+). They don't work for everybody, and they can wear off. That doesn't mean that they don't work at all. We've already seen what happens when nobody vaccinates.

If this guy found out that you could vaccinate
your children but chose not to... 

7.) Medical Malpractice. Here's another point, since I'm a lawyer and I studied health law: Physicians these days practice medicine defensively, in fear of getting sued. Yet they continue to advise their patients to vaccinate and to vaccinate on time. Don't you think that pediatricians would stop recommending vaccinations if vaccinating was anywhere near as dangerous as not vaccinating? Or perhaps their liability carriers would force them to do so, or jack up their premiums??

Instead, doctors are increasingly fearing a new kind of lawsuit: Lawsuits from their immuno-compromised patients and newborns who might come into contact with infected, un-vaccinated children in their waiting rooms. They're discussing a new ethical dilemma: Do they deny care to the unvaccinated, or do they risk creating a highly contagious, potentially lethal waiting room for their other patients?

8.) False Sense of Control. I see a lot of anti-vaxxers say "You can always vaccinate later, but you can't take a vaccine back." Of course, the problem with this thinking is that you cannot vaccinate yourself after you get sick. In this way, the vaccination fears are much like fearing flying more than driving. Driving is far, far more dangerous than flying, but people are more comfortable driving because driving gives them the false sense that they will be able to prevent or minimize any collision because they are in control of their own car.

Another good analogy for vaccination is seatbelt wearing. In almost all situations, it is far safer to wear a seatbelt, and seatbelts have saved hundreds of thousands of lives since they became standard in all cars in the early 1960's. But there are occasional cases in which a seatbelt causes injury ... probably even cases where a seatbelt effectively traps someone in a burning car, causing death. That doesn't make it safer to never wear your seatbelt - or to "selectively" wear it!

Polio: A vaccine success story; completely eradicated
in the U.S. (though not globally, yet). Smallpox too;
Smallpox eradication has been so successful that
we no longer vaccinate for it. Even though there's
an alleged pharmaceutical conspiracy
forcing us to get vaccines we don't need...

9.) Social Contract. Anti-vaxxers get really offended when you try to appeal to their sense of social justice. (Note: If social justice on a certain topic offends you, you might be on the wrong side of things. Just sayin'.).

But the fact is that choosing not to vaccinate is at best paranoid and at worst selfish; anti-vaxxers only have the (false) luxury of not vaccinating because the rest of us continue to vaccinate, thus keeping epidemics back in the history books where they belong (herd immunity). Meanwhile they're endangering not only their own children, but they are especially endangering children who are already suffering from childhood illnesses and conditions like cancer and HIV. These children cannot safely be vaccinated with any live vaccines; their immune systems are compromised, so they would risk contracting the illness rather than having a successful vaccination.

And non-live vaccines are less likely to work for them - plus, they have less of a chance of fighting off any serious illness they contract. I'm sorry, but how horrible would you feel if your paranoid choice resulted in the death of a child who was trying to fight cancer?? Plus, like I said before, vaccines can fail - whether you're immunocompromised or not. Could you live with yourself if your paranoid choice killed someone else's child, or your own?

Because it happens a lot more often than even just the the alleged internet "vaccine deaths." And I think it should be considered negligent homicide. (See this for a discussion of the potential legal ramifications for failure to vaccinate your child).

I'm not writing this blog entry to convince the unconvinceable - and that's why I'm not sugar-coating it. I'm writing it for the people who are on the fence: the middle ground that we've been losing by being too nice about this because there is such an outrageous amount of false and misleading information on the internet that appears reliable.

I have absolutely no bias or financial gain in this equation (neither, by the way do the salaried pediatricians or pediatricians in small practices that sometimes lose money on vaccines, or the history textbooks). I'm not a physician and my husband is going into cancer research. My father is nearing retirement. I have nothing to gain but what I do have is access to two brilliant medical minds who carefully considered this issue when choosing to vaccinate their own children.

My father and my husband have heard, through me, all the arguments brought up against vaccines and expertly batted them away. Perhaps your pediatrician isn't taking the time to do so with you; that might be because hospitals and insurance companies don't pay for or structure lengthy "scientific education" sessions with parents into well-child visits.

Or perhaps your pediatrician has simply given up because it's so rare that he or she changes the mind of someone who is already trying to find their own internet answers rather than trusting the unanimous opinion of all of our leading experts and scientists - see also this recent article on the frustrations physicians are facing out near me in Western Massachusetts.

What I would love to see happen is for each pediatric office to publish a brochure on vaccines that answers the most common questions and addresses the most common misconceptions.

Until then, here's a brief list of resources for the curious.

** And I'd like to just note here that I am unable to "link to" a lot of the sources provided to me for this blog entry. That's because you have to have to pay for a subscription to a lot of the major medical journals and other legitimate scientific sources - or make the big trek to your nearest medical school's library.

In other words, a lot of the best stuff out there isn't available by Googling the internet. And in fact, some of the very worst stuff is- check out this recent sting operation that found that some of the online journals will actually publish fake science for a fee.

** Also, comments will be disabled as of Friday, October 18th. With nearly 500 comments, I can't imagine we haven't covered it all... and I need to get back to doing other stuff with the limited free time I have as a busy mom of two healthy, vibrant, fully vaccinated children.

Many of the comment threads are fascinating and informative, with lots of physicians and other experts responding. A Command+Find search *after* you scroll and upload to the end of all the comments - which you now have to do several times to reach the end - might help you find threads that are of interest to you.

I took care during the nearly one full month since this was originally published not to delete a single comment. So you can rest assured that the integrity of the comment threads is fully preserved.

  • Two articles (this and this) discussing studies that have found that delaying vaccines increases your child's chance of having an adverse reaction (but note that all but ultra, ultra rare adverse vaccine reactions are fairly benign).
  • Pakistan polio outbreak puts global eradication at risk - "Health teams in Pakistan have been attacked repeatedly since the Taliban denounced vaccines as a western plot to sterilize Muslims and imposed bans on [them] in 2012 ... dozens of children, many of them under the age of 2, have been crippled by this disease in the past six months."
  • On vaccine package inserts: "Inserts are a problematic source of information for a number of reasons. They are legal documents, not scientific documents. They do not include science done after the insert was approved. They include ingredients, but do not show you that you are already exposed to those ingredients naturally and how tiny the amounts in vaccines are. They have to report on every adverse event that allegedly happens after a vaccine, whether or not causally related. In short, they are usually more misleading than useful, and my experience is that most readers get them wrong. My favorite was the anti-vaccine proponent who insisted that the vaccine insert said a child cannot eat fruit and vegetables for six weeks after getting the vaccine."

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