An infant girl suffering from pertussis, a vaccine-preventable disease, struggles to breathe. Those indentations in her ribs are one of the signs of her extreme difficulty drawing breath. Via CDC.
What’s not to fear directly about vaccines? There’s a needle that someone pokes into your child. Your child screams. You tense up. What’s in there? you wonder. Viral or bacterial bits that, in ways that are mysterious to a non-immunologist, will keep your child well when intuition seems to say they ought to make your child sick.
Needles, screaming, microbial bits…these naturally would make any parent blanch. The number of vaccines has added to the fear for at least a decade, leading to non–evidence-based calls to “spread out” the schedule or reduce the number of vaccinations.
In fact, the evidence supports the schedule as it’s recommended.
The fear of vaccination is not new. Since Edward Jenner and his cowpox inoculation at the turn of the 19th century, people have latched onto the fear of the known—those needles!—and unknown—what’s in those things?
What might be considered the first anti-vaccine cartoon appeared in response to Jenner’s proposed inoculation of cowpox to combat smallpox.
The vision of cows growing out of arms is comical, but the reality of possible side effects from today’s vaccines can lead some parents to keep their children away from the doctor’s office. Indeed, this anxiety has done so since the days of the 19th century anti-vaccination leagues, aligned against the widespread use of Jenner’s smallpox vaccine.
The vaccine wars in those days were just as bitter and divisive as they are today, including an 1885 march in England in which anti-vaccination forces carried a child’s coffin and an effigy of Jenner himself. Today’s most fanatical crusaders against vaccines may not carry coffins or effigies, but death threats against those who promote vaccines for public health are not unknown.
The fact that the vast majority of parents overcame those fears and had their children vaccinated has led to some of the greatest public health successes of the 20th century. Thanks to the willingness of people to participate in vaccination programs, smallpox disappeared and polio became a thing of the past in much of the world. Indeed, people in those eras knew, often from personal experience, what these diseases could do—maim and kill—and the fear of those very real outcomes outweighed fears of the vaccinations.
But today, we’re different. In the United States, most of us under a certain age have never witnessed a death from diphtheria or tetanus or smallpox or measles. We haven’t seen a child drained of life as a rotavirus rapidly depletes the molecules she needs to live. Many of us have not witnessed the sounds of pertussis, the vomiting, the exploding lungs in an agony of infant death. Why? Because of vaccines.
This very success has, ironically, led to the resurgence of fear and misgiving about vaccines. No longer weighed against anxiety of death or disability from disease, the fear of vaccines now aligns against the bright picture of a nation of children largely free of life-threatening illness.
Without the collective memory of days when children played on the playground one day and died the next of vaccine-preventable disease, the calculus of parental fear pits only the side effects of vaccines against the healthy child. Vaccination requires intentional agency—parental agreement—to impose on that healthy child the very small risk that vaccines carry. Some parents simply are not comfortable either with that intentionality or that risk.
Feeding this reluctance is the explosion of Internet sites that warn against vaccines or disseminate incorrect information about them. The Centers for Disease Control and Prevention (CDC) has provided abundant information about vaccines, including a page devoted to countering erroneous information with facts.
This information will not move the fiercest anti-vaccine groups that lump the CDC in with pharmaceutical companies and others in an alleged conspiracy to harm millions via a money-making vaccine industry. However, it certainly helps concerned parents who simply seek to calm fears, weigh evidence, and make an informed decision about choosing vaccines over the life-threatening illness and compromised public health that result when people don’t vaccinate.
Indeed, these threats to public health have grown considerably with recent large outbreaks of measles and pertussis, including a growing measles outbreak in Europe involving more than 26,000 cases of measles, more than 7000 hospitalizations, and nine deaths as of this writing. The growing threat has led to calls for more stringent requirements for childhood vaccines, including dropping exemptions and requiring that all children be vaccinated over parental objections. This tactic likely would increase vaccination rates among children attending school.
But instead of strong-arming parents into having their children vaccinated, what we really need is a two-fold approach to education. First, we need sober, non-sensationalist reporting from the news media about vaccine-related stories, including stories about side effects, research, and court cases. These articles—and their sensational headlines—are in all likelihood among the prime drivers of the rumor mill against vaccines.
Second, when parents read these stories and turn to a medical professional for input, that input must come as part of a two-way communication between the health professional and the parent, not in lecture format or as patronizing. A little, “I understand your concerns because I’ve had them, too, but here’s what I know that gives me confidence in vaccines,” is considerably better than, “Your child has to be vaccinated, or you can get out of my office.” The onus is on parents to ask with open minds and an understanding that the medical professional in front of them has likely devoted considerable time to gaining the education and expertise necessary to address their questions. Health care isn’t a competition about who knows more. It’s about evidence-based health practices.
As centuries of history attest, no efforts will completely eradicate vaccine fears. Motivations fueling anti-vaccine sentiment that go beyond information gaps range from personal economic benefit to a desire to out-expert the experts to the inertia of fear.
But a careful and persistent information campaign and outreach efforts from medical professionals in the trenches may help keep vaccination rates sufficiently high. Parental investment in gaining information from trained professionals and making decisions based on facts rather than fear is also an indispensable component. To ensure adequate rates requires either these efforts or a resurgence of the deadly diseases that have graphically demonstrated the real balance of the threats at issue here.
Which one would we rather have?
Emily Willingham, Double X Science Editor Twitter, @ejwillingham ———————————————————————— A version of this post originally appeared on the blog of PKIDs, Parents of Kids with Infectious Diseases. The mission of PKIDs includes educating the public about infectious diseases and methods of prevention and transmission. Follow PKIDs on Twitter @PKIDs.
The flu season that is unfolding is a killer, with influenza having already taken dozens of lives across the United States. Deaths from flu during the flu seasons are actually the norm, ranging from 3000 to 50,000 annually, but this year’s outbreak arrived early and features a strain that is infamous for its virulence. Forty-four states now have met the cutoff for “widespread” flu activity as of this writing, and in hotspots like Boston, MA, cases are 10 times the number from the same time last year. In many areas, hospitals have taken to setting up temporary tent shelters outside the buildings to manage the flood of cases and prevent spread inside the facility. ETA: This USA Today article gives an overview of how clinicians are experiencing this outbreak on the ground. [Update: As of 1/18/13, a total of 48 states are now at widespread status, and 29 children have died. Forty percent of hospitalized children have had no known underlying medical conditions.]
Public health officials from the US Food and Drug Administration and the Centers for Disease Control and Prevention(CDC) are urging people who have not gotten their flu shots to do so, saying that there is still time for the vaccination to work for you against the flu. The most vulnerable population is children, and 18 children have already died in the United States during this year’s season. According to reports, far less than half of the eligible population in the US has gotten a flu vaccination.
People express reluctance to get the flu vaccine for several reasons. Among them are fears that the vaccine contains mercury as part of a preservative, thimerosal, that has been used for years in various immunizations, although it’s been removed from many. For the flu, only vaccines from multidose vials contain this preservative, which is needed to protect the contents from contamination when the vials are opened for repeated use. Single-dose shots and the inhaled Flu Mist do not contain this preservative, which an abundance of studies have shown does not cause harm despite diligent efforts from anti-vaccine organizations to argue otherwise. For more information about this preservative in multidose vials of flu vaccines, the CDC offers a Q&A.
Another source of reluctance is the fact that the flu vaccine, like several other vaccines–or indeed, having the infection itself–is not 100% protective against the illness. In fact, it appears to be about 60% effective in preventing illness, although those who have been vaccinated and do fall ill with the strain included in the vaccine might experience less intense symptoms. The CDC also offers a Q&A addressing why some people who have been vaccinated still catch the flu. My personal feeling is that I’d rather give my children that 60% chance in a rampant flu season with a virulent strain that’s hospitalized tens of thousands than give them no protection at all. Any number of interventions don’t carry a 100% guarantee of effectiveness, but they certainly enhance the favorable odds. My children and I all received the Flu Mist vaccine back in October. ETA: A recent report found that different forms of the vaccine have different levels of effectiveness in different age groups and that the vaccines and vaccine program require improvement. For more information about the report, which concluded as we’ve written here that flu vaccines offer moderate protection and have a good safety profile, please see this post by an epidemiologist.
People also forgo a shot because they think that only people in poor health or with pre-existing conditions are susceptible to the most dreaded outcomes with flu: hospitalization and death. That’s not actually the case. “Influenza” is the name we give to the highly variable viruses that play games of genetic mix-and-match in different species, with results that are unpredictable and rapidly changing. No one’s previous experience with flu will necessarily be predictive of later experiences with the virus. Some flu strains do hit certain populations with specific existing health problems, but other strains kill the young and healthy preferentially. And whether or not you yourself are in perfect health, if you get the flu, you risk passing it along to someone who is not. ETA: For a personal look at who some of those people are, please see the Faces of Influenza site. Some people cannot get a flu shot for medical reasons, and anyone who has had a reaction to a vaccine should obviously consult with their medical professional about vaccines.
A final source of reluctance is that the flu vaccine each year is developed based on educated guesses. No one can predict with certainty which strains will gain the upper hand. As it happens, one strain in circulation this year falls outside of the vaccine target, but medical authorities report that so far, 91% of strains identified in circulation are targets of the vaccine. Because we are talking about influenza and several circulating strains, if you do not get a vaccination, it’s entirely possible for influenza viruses to hit you or your family hard more than once this flu season.
Bottom line? Without a vaccination, you’re 100% exposed no matter what your age, health, diet, exercise routine, or supplement intake. And if you get sick, you’ll endanger everyone you’ve been around and contaminate every place you’ve been. Flu carries innumerable potential and unpredictable outcomes, from complete recovery to death, and hospitalizations this year are extremely high. People with a genuine case of influenza end up floored for days, in body-wide pain, with high fevers and wracking coughs and a risk for pneumonia, hospitalization, and death, sometimes with unpredictable rapid progression. Even for those who don’t end up in the hospital, complete recovery from these deadly and unpredictable viruses typically takes weeks, meaning lost school, lost productivity, lost work, lost wages. Meanwhile, the vaccine cost ranges from free to about 20-40 bucks at various pharmacies.
Here is a basic video explaining some of the complexities of the flu vaccine and its success rate:
The opinions expressed in this article do not necessarily reflect or conflict with those of the DXS editorial team or contributors.
Several articles published in Pediatrics today discuss an issue that could affect the protection of children everywhere from vaccine-preventable diseases. The posts center on a controversy that keeps coming up related to vaccines – the use of thimerosal in them.
All three Pediatrics articles deal with the same thing: an international treaty drafted by the United Nation Environmental Program’sGlobal Mercury Partnership to reduce mercury pollution and environmental mercury exposure across the world. Great! This is an important and valuable initiative – except for one part. As part of the treaty, the UN wants to ban the use of thimerosal, a mercury-containing preservative, used in vaccines. Not so good. The short version for why? This proposed ban threatens millions of children’s lives across the world, including children in the U.S. and in other developed countries. I’ll get to the long version in a moment.
Here’s the back story:
A 1997 US FDA review of the mercury content in products revealed that the amount of thimerosal in childhood vaccines could, possibly theoretically, build up to exceed the EPA’s guidelines (but not the FDA’s guidelines or those of the Agency for Toxic Substances Disease Registry) on safe exposure limits for inorganic mercury, called methylmercury.
Methylmercury is the neurotoxin you hear about when you’re warned not to eat too much fish ( especially while pregnant). Back in 1999, scientists knew a lot about methylmercury, but they didn’t know much about ethylmercury, the type in thimerosal. As Dr. Louis Cooper and Dr. Samuel Katz, both involved with the 1999 recommendations, put it, “the absence of clear data for ethylmercury did not allow any assumption to be made about its safety.”
Meanwhile, debates were raging in Congress about concerns over vaccines and autism, fueled by the now-retracted and thoroughly debunked (pdf) study by Andrew Wakefield linking the MMR vaccine to autism. Parents were scared and confused. Media coverage was exacerbating the impression that public health officials weren’t being forthright about vaccine risks.
So, poof! All thimerosal was pulled from childhood vaccines except the multi-dose flu vaccine, since kids getting that would only get amounts below the EPA guidelines for methylmercury (even though, again, thimerosal is ETHYLmercury).
Now fast forward to today. We know a LOT more about ethylmercury: namely, that it’s not as bad as methylmercury and sails through our bodies a lot more quickly. In fact, methylmercury’s half-life is about seven times that of ethylmercury, which does not build up in the body like methylmercury does.
“There is no credible scientific evidence that the use of thimerosal in vaccines presents any risk to human health,” writes Dr. Katherine King in one of today’s Pediatrics articles. Dozens of studies and a massive review at the Institute of Medicine back this up.
Thimerosal in vaccines is not a problem. But what is a problem is thimerosal’s PR image. Again, from one of today’s AAP articles: “Given the complexity of the science involved in making guidelines, the polarity between vaccine advocates and those believing their children have been harmed, the media’s attraction to controversy, and, in retrospect, inadequate follow-up education about the issues to clinicians and the general public, it is not surprising that the steps taken left misunderstanding and anxiety in the United States and concerns in the global public health community.”
Basically, they’re saying, yea, we kinda screwed up with conveying that thimerosal really IS safe after all. We wanted to be over-cautious before, and we were, and that was good, but now we’ve sorta dropped the ball on following through in letting you know that YOU HAVE NOTHING TO WORRY ABOUT with the ethylmercury in thimerosal. As Dr. Walter Orenstein today’s AAP articles, “Had the evidence that is available now been available in 1999, the policy reducing thimerosal use would likely have not been implemented. Furthermore, in 2008 the World Health Organization endorsed the use of thimerosal in vaccines.”
But apparently, the WHO’s endorsement can’t overcome thimerosal’s PR image problem in the eyes of the UN. And so the UN is short-sightedly and dangerously trying to ban thimerosal in vaccines.
Well, that just means getting rid of it in flu vaccines (many of which don’t even have thimerosal since they’re single-dose), so what’s the big deal anyway? The big deal is that not all countries got rid of thimerosal in their childhood vaccines. Many high-income countries like the U.S. did – because they could afford to be overly cautious.
But more than 120 middle- and low-income countries – including the developing countries where vaccine-preventable diseases have the highest rates of infection and death – have continued using thimerosal-containing vaccines because the preservative allows them to make cheaper vaccines that withstand less rigorous storage without compromising safety.
Getting rid of thimerosal would mean overhauling vaccine production and storage in those countries, which the WHO estimates would cost more than $300 million for vaccines supplied by UNICEF or the Pan American Health Organization alone. As Dr. King argues, “it is banning thimerosal that would cause an injustice to those living in low- and middle-income countries and relying on these vaccines for effective protection against many harmful infectious diseases.”
Why does this matter to people in the U.S. or in other higher income countries? Because we live in a global world. Vaccines with thimerosal are currently used to immunize about 84 million children across the world every year, saving an estimated 1.4 million lives from vaccine-preventable diseases.That also includes lives saved in developed countries, where a future outbreak could potentially be imported from other countries in which a vaccination program may have ceased following a thimerosal ban.
More simply put: If the UN forces the removal of thimerosal from vaccines, then 84 million children risk not getting vaccinated (and/or vaccinated on time) due to delays in vaccine production or due to a shortage of vaccines because of increasing costs. This, in turn, could (and likely would) mean an increase in vaccine-preventable infections, which will, in turn, kill more children worldwide and risk disease carriage to other countries.
Over and beyond the increases in vaccine-preventable infections and deaths throughout the world, a thimerosal ban in vaccines could also still pose problems for developed countries. In an emergency, as Dr. Orenstein and colleagues argue, not being able to manufacture vaccines with thimerosal could endanger lives during an epidemic if it slows down vaccine production. This proposed UN ban – and the necessity of its removal – matters.
Dr. Cooper and Dr. Katz – again, both pediatricians who were closely involved in the original 1999 decision to pull thimerosal out of vaccines – sum it up best: “The World Health Organization recommendation to delete the ban on thimerosal must be heeded or it will cause tremendous damage to current programs to protect all children from death and disability caused by vaccine-preventable diseases.”