Here we go again…all over again

Much has been written so far today about Jenny McCarthy joining The View as host, replacing Elisabeth Hasselbeck (who will apparently be joining Fox News in a not entirely surprising turn of events). Excellent pieces by Seth Mnookin, Wendy Sue Swanson, Claire McCarthy, (no relation?) and Phil Plait have said far more, and in a more eloquent manner, than I could hope to. Suffice it to say, I lend my voice to the chorus of educated, pro-science docs and science writers who recognize this for the public relations—nay, public health—fiasco that it is. Giving a bigger and louder mouthpiece to a woman who does not need one, and who uses it to say anti-vaccine, pseudoscientific drivel, is frankly dangerous.

People listened to Jenny McCarthy over the years and look where it got us: a measles outbreak in Brooklyn, a pertussis epidemic in California. And on. And on. Jenny McCarthy has indirectly contributed to disease and to death and my fear is she will continue to do so when she begins her new job on The View. Maybe she will prove me wrong. Maybe the years of writers like Seth Mnookin and Paul Offit and the disgrace of Andrew Wakefield have all served to cow her. Uh huh. And I’ve got a bridge in Brooklyn to sell you…

Given that she is being hired by ABC precisely to drum up viewers and spice up the ratings, I have to think they know exactly what she wants to say and are all too happy with her saying it. The ensuing controversy and uproar (look, it’s already started and she hasn’t even said anything yet!) are what the network wants to have happen because they generate what advertisers want: tweets, Facebook likes, web page hits, viewers, eyeballs, mindshare. Viewers over vaccines. Ratings over remedies. I think I finally figured out what ABC may end up standing for: “Adding to the Body Count”.

(I realize I am probably adding a tiny amount (how many people do you think read this blog?) of fuel to the fire by writing about this—adding to the attention Jenny McCarthy and The View are getting and may continue to get. I can only hope that when ABC sees the sheer quantity of bad press and social media mentions they are getting by this decision that they will reconsider it. Or at the very least, that we all can help educate people and discourage them from watching The View in coming seasons.)

Rounding up the Herd

As I have discussed in a previous post here, Pertussis, also known as whooping cough, is increasing in prevalence. There are outbreaks this year across the country, building on previous outbreaks last year and in 2010. In order to control these outbreaks, there are a number of strategies being suggested to increase immunization rates—from adding another adolescent dose of the vaccine, to increasing adult vaccination. However, one prominent population that has been a focal point in these outbreaks cannot currently be vaccinated: infants under 6 weeks of age, for whom the vaccine is not approved (pertussis vaccination starts with the routine shots at 2 months of age). How can we protect these infants?

A recent post on’s twitter feed linked to an article about the possible introduction of a newborn pertussis vaccine. This is a wonderful idea and could certainly help to address protection of infants from pertussis. However, either testing either the current DtaP vaccine or developing a newer version for use in this population are time-consuming propositions, both. On the order of years. And that will do nothing for people currently at risk from outbreaks currently in progress. There is another way to protect infants though, one that relies on the concept of herd immunity.

Herd immunity is the idea that by vaccinating a large enough number of individuals in a population–the “herd”–we will effectively halt transmission of the disease because there are not enough potential susceptible hosts. Thus the people who are unable to be vaccinated—infants in this case—will be protected by virtue of being surrounded by immune individuals. In the case of infants, this surround effect is rather evocatively called cocooning, with the idea of blanketing a baby with healthy, vaccinated people. This is accomplished in practice by vaccinating an infant’s mother, father, and caretakers. Previous efforts to accomplish this had relied on vaccinating the mother during pregnancy and encouraging others to be vaccinated during the same time period. But nearly every baby in the US is born in a hospital or similar facility and stays in the nursery for 2–4 days. Could the family be vaccinated then? The answer is a most emphatic yes!

Here in New York State, thanks to brilliant research and lobbying efforts of Shetal Shah, MD, a colleague of mine here at Stony Brook, this practice of cocooning— by encouraging vaccination of caretakers prior to the infant’s discharge home from the hospital—will now be law. Through work published in the journal Pediatrics in 2008, Dr Shah showed that the practice of vaccinating parers and caretakers prior to NICU discharge (Dr. Shah works in the neonatal intensive care unit) was well-tolerated, feasible, and effective. As the rather thorough press release explains, beginning January 2013, all parents and caregivers will be offered and encouraged to accept pertussis vaccination before taking their baby home from the hospital. The hope and aim is this will help to prevent pertussis cases in these infants in the event of an outbreak.

I for one am proud to live in a state so responsive to appropriate medical lobbying efforts, and so proactive in its vaccination practices. The next step is to broadly implement similar cocooning practices across the country and encourage similar laws in state legislatures elsewhere. Let’s get started!

On Cows...

Today’s topic is vaccines and vaccination. And you thought I’d be writing about farm animals

From the Latin for “cow,” vaccination owes its name to the first virus used in a vaccine: Cowpox or Vaccinia virus. Edward Jenner first performed vaccination in 1796 when he successfully inoculated a young boy, James Phipps, with cowpox and thus protected him against smallpox. The term now applies much more broadly to the inoculation of a person with some or all of any infectious organism in order to induce immunity. It is one of the most incredible discoveries of modern medicine and widespread vaccination has transformed our world:

  • Infant mortality has greatly decreased, at least due to infectious causes, despite claims to the contrary.
  • Previously widespread childhood morbidity and death from infections like meningitis and pneumonia is decreasing.
  • Certain previously widespread cancers, like the subset of liver cancer caused by Hepatitis B, can now be prevented by vaccination against the causative agent.

However, vaccines and vaccine-preventable diseases have been in the news recently not because of our triumph over them, but for other reasons:

  • Measles, reported eliminated from the United States in 2000, has now been seeing a rise in cases. In 2011 there were 222 cases, 40% of which were imported from other countries, but many of the others were in under-vaccinated children.
    • One outbreak in Minnesota in particular affected 6 children whose parents had willfully withheld the MMR (measles-mumps-rubella) vaccine due to concerns over autism.
  • Pertussis cases have been rising overall for the past 2 decades, and outbreaks are becoming more frequent. With a 27,000 case outbreak in 2010, and despite a brief decline in 2011, Pertussis is on track to beat it’s recent peak–22,000 cases so far in 2012. Perhaps most horrible about this year’s outbreak is the 13 deaths–these all in infants too young to receive the vaccine.
    • It has been repeatedly reported that much of 2010’s outbreak was due to intentional undervaccination by parents; 2012’s outbreak in Washington State is similar.
    • See the chart below, courtesy of the CDC: pertussis chart.

And finally, on a more personal note, I will present the story of a young girl I cared for whose pediatrician had intentionally withheld the varicella vaccine–that’s the one against Chicken Pox. This shot is usually given at 12 months of age, but he withheld it until a planned visit at 15 months of age due to “too many shots” being given at the 12-month visit. The patient never needed her varicella vaccine.
At age 13 months she was admitted to the Pediatric Intensive Care Unit at my hospital with severe chicken pox and, more significantly, severe sepsis and neck muscle and soft tissue infection with Group A Strep. This bacteria is known to complicate chicken pox in this way, and the rate of this complication is in fact a reason for the vaccine in the first place. She survived, but only after a weeks-long ICU and hospital stay, intubated, on a ventilator, near death for the first few days of her course.

You tell me which is worse–one extra needle in the leg or the course of treatment above?

The reasons why people under vaccinate their children have been described to death by many others far smarter than I. Two excellent books on the subject are Autism's False Prophets and Deadly Choices. Dr. Paul Offit, the author of these books, also writes an excellent guide to parents called Vaccines and Your Child. I highly recommend all of these.

Similarly, the fact that none of the side effects and poor outcomes reported by those in the anti-vaccine movement have been held up by scientific evidence is now abundantly clear. Numerous strong epidemiological studies have shown no link with autism and Andrew Wakefield himself, the inventor of this myth, has been discredited and shown to be an outright fraud. Thimerosal is out of vaccines. Whole-cell pertussis vaccine is off the market. Every concern the anti-vaccine movement has raised that is even possibly scientifically valid (and many that aren’t) has been addressed through rigorous study or alteration of vaccines.

So you have science on the one hand and fixed false beliefs on the other. This duality has happened before with other issues in society. And I understand the hesitation of other facets of society, such as the media, to try to change individuals’ beliefs. We live in a country where freedom of thought and action is paramount. Except, however, when that action does demonstrable harm to others. Ignoring even for now the issue of their own children or patients, which I’ll address below, parents and doctors who withhold vaccines are harming other people’s children as well; children too young to be vaccinated regardless of parental wish, like those in the recent pertussis outbreaks. We’re beyond the choice of individuals like Jenny McCarthy and now the action of a minority has the potential, and is starting to hurt and even kill many, many others.

Ultimately, I should not have to write this.

The answer is simple: just give the damned shots.

Vaccines save lives. That fact is about as crystal clear as anything in science or medicine today. Many children died from these diseases before we could protect against them. Now that people don’t vaccinate again, children are dying again. These deaths are senseless, needless deaths that are entirely preventable. I understand vaccines represent a Big Black Box to most parents–they are an unknown. The immune system is an unknown. ‘Who can tell me that my child will not suffer after receiving this vaccine?’ Well, your pediatrician can. Medicine can. Science can. And it has done so repeatedly over the past 10–20 years since this issue came to the fore.

Vaccines are safe and have clear benefit. Withholding a vaccine from a child, either as a pediatrician or a parent, is potentially equivalent to withholding surgery from someone with appendicitis or withholding antibiotics from someone with strep throat. Sure, the kid without the vaccine may not get sick. The kid with strep throat also may not get rheumatic fever. But are you willing to take that chance with your child? With your patients? And if we aren’t for the other examples I gave, why are so many willing to gamble with vaccines?

Nowhere else in medicine is something with such clear benefit allowed to be a subject of debate. In fact, in many states, parents who try to take their hospitalized children out of the hospital against medical advice or withhold life-saving treatment can be prevented from doing so if there is clear benefit to the child. But we can’t force vaccines on our patients. The reason for this has never been clear to me. Hopefully, after reading this and clicking the links and learning more about what is now happening because of undervaccination, the reason will become unclear to you, the reader, as well.

Vaccinating saves lives. Undervaccinating hurts and even kills. It’s not too late for us make the choice ourselves. Or someone, someday, will make it for us.