An Update on Vaccines

In the days since my article on vaccines I have received a lot of feedback. Many readers have been very supportive but some have taken issue with some of my arguments, my mode of presentation, or raised questions that I did not answer. They presented a variety of valid, or at least understandable, concerns which I will take the opportunity to address here. At the request of those who contacted me I will respect their desire to remain anonymous.

I feel as though you did readers a disservice in not even casually mentioning any of the adverse effects of vaccines

The Institute of Medicine (IOM) document the reader linked to is an excellent summary statement on both established and unclear adverse effects of vaccines. I did not delve into this due to space considerations and the nature of the story I wanted to tell. But they are absolutely right, vaccines are not without some degree of adverse effects, side effects, and/or allergies. Most of these, however, are mild and do not compare in severity to the impact of a single infection with a vaccine-preventable disease, let alone an outbreak. And the adverse effects that are unprovable or unclear in their associations, by virtue of their uncertainty, are not worth using as a basis for vaccine policy; certainly not in the face of stronger evidence arguing for continued vaccine use. This is the ultimate conclusion of that IOM document cited above

In your article, you cited pertussis outbreaks as one of the strongest reasons to vaccinate, but you didn't give empirical evidence that the current outbreaks are actually related to under-vaccination.

We do in fact have a number of studies (I give one here as an example) that show that the lack of vaccination with pertussis specifically is a real and significant factor for increased outbreaks. Similar studies have been done for other vaccines.

A doctor at UCLA said “...the possibility that the pertussis bacterium has mutated ‘is an important hypothesis to test.’” Couldn’t this be the cause of outbreaks and increased disease?

This is absolutely true--this is an important hypothesis to test. There is a recent study from February in the New England Journal of Medicine that shows a number of strains have mutated to lose an antigen--Pertactin--that is contained in the vaccine. Is this a part of the reason for increased disease? It might be--we just don’t know. There will certainly be studies done by this group as well as others to look at the changing epidemiology of the circulating strains of bacteria. But even if this is multi-factorial (which for pertussis it almost certainly is--see below), not vaccinating still plays a major role.

In trying to objectively assess the risks of not vaccinating my children for pertussis, I see evidence that seems to be starting to lean toward the possibility that vaccination isn't even effective.

There is indeed some evidence that with the newer acellular Pertussis vaccine rolled out in the late ‘80s/early ‘90s, there is waning immunity over time, in particular between the 4-6 year and 11 year vaccine doses. However, this is a reason to develop either a new more immunogenic vaccine, or to add an extra vaccine in to the schedule to keep immunity up (until a new vaccine that lasts longer can be made if that is possible). The solution is not to further dilute the vaccine schedule or delay vaccinating.

It seems as though there are 100x more studies trying to prove the effectiveness and safety of vaccines than there are studies of adverse effects.

In fact, any study that addresses the safety of a new vaccine is by definition looking at adverse effects. Any new product that is approved has to go through a standardized FDA protocol, even vaccines, and even back in the 60’s when the older ones such as MMR were made. The newer ones go through rigorous safety evaluation including short- and long-term follow-up.

From my understanding, the reporting of possible vaccine reactions is not compulsory, so it's probably underreported — maybe even severely underreported given the aforementioned bias — and yet there are hundreds of thousands of reports of adverse vaccine reactions...Since I’m not a doctor it’s hard for me to find and parse medical literature. Are you aware of any strong studies done on the VAERS data itself and the likelihood of underreporting?

VAERS is indeed problematic. It uses passive reporting--there is no organization that actively seeks out adverse events. Instead doctors or others must report events themselves. In fact, the nature of VAERS is that anyone can report, not just a physician. And as was rightly said, many physicians are ignorant of VAERS and so do under-report. There are also MANY studies on VAERS, both about it in general and specifically making use of its database. Pubmed is a repository of many, many, many published studies (essentially all journals--though some aren’t indexed, all the major ones are)--go to their main page and just type in VAERS; many examples of VAERS-related studies will show up.

A caveat too about VAERS: because VAERS only catalogs associations, it would be possible to walk out of a doctor’s office after getting a tetanus shot, go drive away, and get hit by a car; and then you could have someone file a VAERS event saying that the tetanus shot was associated with the car accident. That would be a hard sell from a scientific standpoint. And since anyone can report, many with an axe to grind do so there, so we all need to take the VAERS data with a teaspoonful of salt.

In my research of the polio vaccine, it seems as though a person in the United States is now statistically more likely to get polio from a vaccination than from the live virus.

That used to be the case when we gave OPV, the oral polio vaccine, which contained live virus. That was phased out in the US in 2000 and this is continuing in more and more other parts of the world as the disease is eradicated. We have switched to IPV which does not have any live virus and so does not carry a risk of transmission. The only polio seen in the US since 1979 has been imported from other countries or, as above, before the early 2000’s, due to the vaccine. In recent years (since the late 1990’s) there has been no imported polio from other countries either. In fact, the reason I spent not much time on polio in my article is that this is indeed a vaccine that may be able to be phased out in the next few years, as Smallpox was, because of global eradication efforts--due to vaccination.

I hope you are catching on to the fact that I'm not a Jenny McCarthy type, mindlessly regurgitating bad data and mythology. I'm a dad having a deep intellectual battle over what’s best for the children I love. It’s unlikely that my kids would be harmed — especially severely — by vaccines, but it would tear me up if they were. It’s also unlikely that my kids would be harmed by not being vaccinated, but it would tear me up if they were.

I hear this comment loud and clear. And yes, the reader is right, the risk of catching measles or whooping cough, even with outbreaks and rising rates, is still small. And the risk of some similarly severe life-threatening event from a vaccine is small. Nobody knows for any single child what their chances are of getting whooping cough without being vaccinated--it depends on their contacts, exposures, etc. But similarly, nobody can tell you what the odds of one of your children having anaphylaxis due to a vaccine is. We can quote overall rates and populations, but individual patients are not populations and so the numbers don’t predict the small scale single events.

Part of the reason I still haven't done any vaccines with my children is because doctors wouldn't engage with my wife and I on a rational level. Which probably has to do more with fear and malpractice insurance, but it's a pretty sorry state when pediatricians live in fear as one of the most sued branches of medicine. We had several doctors completely refuse to see our children unless we followed the exact recommend vaccine schedule. And when we brought up safety concerns they pulled the same fear mongering everyone accuses the anti-vaccine crowd of using inappropriately.

I don’t think that’s true about pediatric malpractice suits--our rates of lawsuits are one of the lowest in fact, at least as of a NEJM paper from 2011.

Now, the refusal to see parents who either don’t vaccinate or wish to use a different schedule is a hotly debated topic among general pediatricians. Some feel that turning away patients is unethical. But some feel that to not vaccinate is also providing unethical & substandard care, doing harm and violating the Hippocratic oath. It is not about money or lawsuits or malpractice in a legal sense or risk, it is about professional ethics and our own code of morals--and this is, in fact where I fall. And again, maybe that’s unfair of us to so judge both ourselves and our patients. But for docs who view delaying vaccines as harming a child, you would not want them to see your child because they would be violating their interpretation of the Hippocratic oath to do so.

That's another aspect of your article that bothered me. I get that you were trying to create a "better narrative", but using the same unsound tactics as the opposition is not how a better narrative is created.

Well, the point of my piece was really that for a particular subset of people, data on its own does not work. Numbers and studies and such, while they may help you to decide, aren’t going to work on, for example, Jenny McCarthy. And my point was that in those settings, anecdote together with data helps reframe the story in terms that some people can get their heads around. This is not ideal. It does not make my own scientist-brain happy. But if it gets my patients what they need, it may be a necessary evil with certain folks who can’t hear things any other way.

And the term “a better narrative” was not to say that anecdote or fear-mongering is better than data--it’s specifically about the idea of integrating a more personal illness narrative aspect into our work on our side, given that they have done so on theirs. Some interesting writing on the idea of “narrative medicine” has come out in recent years--if you’re interested, I recommend you look into Rita Charon, Arthur Kleinman, and the Columbia University program on Narrative Medicine.

I thought it was incredibly unthoughtful of you to lump "reducing the number of vaccines, eliminating additives to vaccines, and altering the vaccine delivery schedule" into the jumble of myth and psudo-science you were trying to debunk.

That’s a fair point. I was trying to flesh out Jenny McCarthy’s position, but may have overdone it. That said, I would argue, outside of Polio being eradicated, the idea of reducing vaccines really isn’t safe or appropriate. And the vaccine schedule has been studied to death--every time a new vaccine is introduced they study it in combination with other vaccines to see when it should best be given. A random schedule thought up by Dr. Sears or Jenny McCarthy or someone else just doesn't have the same weight as one studied by multiple experts and panels. That leaves trying to eliminate additives to vaccines, which I’ll grant is a very reasonable idea that has in fact been and is being studied (search Pubmed for legitimate studies on Thimerosal to start).

My view is that scientists should be embracing the anti-vaccine group as the ultimate control group for long term studies about vaccine safety (similarly, the kids who are on alternative schedules). If parents are going to contentiously (sic) object to giving their children vaccines, it should at least be used to further the science of vaccines!

Scientists are already doing so at least with regard to some issues. But controlling for all the possible interfering factors and coincident conditions in these two patient populations is very difficult. The other issue is that many parents who don’t vaccinate are untrusting of medicine and don’t want to participate in surveys or long-term studies. The exception is some of the surveys administered by known anti-vaccine groups but there the element of bias is so strong it is impossible to know what to make of any results.

That said, see here or here for studies that try to compare across these groups and look at adverse reactions, infections, allergic issues, among other things.

feel free to use any of this for a "frequent objections" post on your blog.

Will do!

Hopefully this serves to clear up some issues and confusion. And to those who I have not yet convinced, well, I may never do so but it doesn’t hurt to try!