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 past few weeks have seen big news for vaccines. A bill related to vaccine exemptions was signed into law, a court ruled against a parent’s refusal to vaccinate and a recent study points out the value of vaccinating a household — especially mom — to protect a young infant from pertussis (whooping cough).
The latest news is that Governor Jerry Brown in California signed a bill last Sunday that had been sitting on his desk since September 6 and was the target of a number of rallies by parents who didn’t want to see it pass. Among those fighting the bill was Dr. Bob Sears, who says he walks a middle ground with vaccine policy but in reality tends to flirt with those who fear vaccines and rely on misinformation. Although some parents claimed the bill took away their right to choose whether their children get vaccinated, it actually just ensures they get good medical information before they make that choice.
Photo by Dave Gostisha at sxc.hu.
The bill-now-law, AB 2109, proposed by a pediatrician, requires parents to get a statement signed by a health care practitioner that the parents/guardians have received accurate, evidence-based information about the risks and benefits of vaccines before they can use a personal belief exemption to prevent their children from being vaccinated. This law is a tremendous triumph both for informed consent in medical decisions and for the public health of children in California, which saw a considerable outbreak of pertussis (whooping cough) in 2010. Washington state passed a similar law last year and saw 25 percent drop in exemptions filed. Other states are considering similar laws in a nationwide overall shift toward strengthening exemption requirements.
Why are these laws so important? In short, they kill two birds with one stone: They make it more difficult for parents to casually opt out of vaccines on philosophical grounds (as opposed to religious or medical reasons), and they require parents who want to opt out to at least hear out a pediatrician on accurate information about the actual risks (which do exist) and benefits (there are so many) of immunizations. Parents who are determined not to vaccinate their children can still refuse, but many parents who might have signed those forms out of convenience — it can be easier to sign than to get to the doctor’s office for the shot — will now at least hear the impact a decision not to vaccinate can have on the community. (Hopefully, they go to a health care practitioner other than Dr. Sears, whose stances have gradually been moving further and further toward unscientific and misinformation of those who oppose vaccines.)
It’s also particularly notable that California and Washington are the most recent states to tighten opt-out procedures for parents because they are home to some of the more recent pertussis outbreaks. More on that in a moment.
First, a bit of background on vaccine exemptions: Only 20 states have personal belief exemptions, and until last year, eight of these simply require nothing more than a parent signature. Now that number is down to six. (Other types of requirements for philosophical exemptions include writing out your reasons for exemption, requiring the forms to be notarized, requiring education on the risks/benefits, direct involvement from the state or local health department or renewals.)
All states have medical exemptions for patients who have auto-immune disorders, have proof that their bodies do not respond to immunization, have documented allergic reactions or have other circumstances which make it too risky for them to be immunized. In fact, these are the very people that the rest of the population protects through herd immunity when vaccination rates are up where they should be. All but two states have religious exemptions (Mississippi and West Virginia are the exceptions).
And that brings us to some less covered but still significant news about one state’s ruling on a particular case involving religious exemption. Last week, the U.S. district court in Ohio ruled that one woman’s claim of religious objection was insufficient for her children to be exempted from being vaccinated. Read the whole story here. To be fair, this is a complex case involving far more than vaccines; the mother is clearly neglectful and the overall situation is pretty crappy. However, the fact that the court found “the mere assertion of a religious belief … does not automatically trigger First Amendment protections,” and that “it has long been recognized that local authorities may constitutionally mandate vaccinations” is significant in a state that offers both religious and personal belief exemptions.
The constitutionality of religious exemptions is dubious as well. At the very least, however, anyone seeking any exemption should certainly to see a doctor first to be sure they have accurate information and not simply what they have seen online or heard at the playground. Those who absolutely will not vaccinate in states without exemptions may also opt to home school or send their children to private schools that don’t have requirements. But considering the increasing rates of measles and the increasing epidemics of pertussis, the need for high vaccination coverage in communities is more important than ever.
It is true that the pertussis vaccine is not as effective as the old one used to be, something I wrote about a few weeks ago. It’s also true that pertussis peaks every five years or so, but even taking into account the peaks, the overall rate of cases has been steadily on the move upward. Dr. Offit, the chief of the Division of Infectious Disease at Children’s Hospital of Philadelphia and a very vocal advocate of vaccines, said he believes that parents’ refusals to vaccinate are playing their own small part in the increase.
“The major contributor is waning immunity. The minor contributor is the choice not vaccinate,” he said. He noted that there are researchers working on the problem, as this Nature article notes (paywall), including attempts to make a better vaccine with more adjuvants, the additives that enhance the body’s immune response to a vaccine. While vaccinated children and adults have been high among the numbers of those getting whooping cough, getting the vaccine remains among the best ways to reduce your risk of contracting it — or of having less rough of a time with it if you do get it. Dr. Offit also pointed out that pregnant women in particular should be sure they get their booster.
Which brings us to the study published last week that relates to the most important reason to get vaccinated, at least from the perspective of preventing deaths — to protect the babies who are too young for the vaccine but most likely to contract it and die from it.
The study, published in the journal Epidemiology last week, looked at how frequently pertussis was transmitted to others within the same household and how effective “cocooning” is. Cocooning is vaccinating all the household members who can get the vaccine for the purpose of protecting young babies who can’t yet be vaccinated for the disease.
They found that transmission rates within the home are high, especially for mothers passing the illness on to their children. Therefore, making sure all pregnant women are vaccinated before their baby arrives would, according to their calculations, cut the risk in half that a baby would contract pertussis. The evidence for sibling vaccination, though weaker, still points to the value of overall cocooning: “Vaccination of siblings is less effective in preventing transmission within the household, but may be as effective overall because siblings more often introduce an infection in the household.”
Indeed, this year, siblings’ bringing home the disease appears more likely than ever in the states experiencing big outbreaks this year. Just how bad are the numbers? Well, 2010 was the last five-year peak, which totaled 27,550 cases. It’s currently September of 2012, and the numbers last reported to the CDC were at 29,834, and that doesn’t even include over 3,700 cases in Minnesota that haven’t been officially reported to the CDC yet. These numbers, which include 14 deaths (primarily of babies under 3 months), may very well end up doubling the 2011 total of 18,719 if they continue at the current rate through the end of the year. It’s the biggest pertussis outbreak since 1959.
Not surprisingly, the majority of the states leading in pertussis cases are also among those that offer personal belief exemptions. Washington, despite their new law, is sitting at 4,190 cases, quadrupling their 2011 count of 965. This is the state where 7.6 percent of parents opted for exemptions (among all grade levels, not just kindergarten) in 2008-09, more than four times the national rate of about 1.5 percent. Minnesota and Wisconsin have similarly high rates and both have personal belief exemptions. The most recent numbers out of Minnesota are 3,748 — they had just 661 cases last year. Wisconsin is leading the nation with 4,640 cases, up from 1,192 in 2011, at last report in the Sept. 28 Morbidity and Mortality Weekly Report (pdf) at the CDC.
But the increases are being seen across the nation, as this CDC map shows. Texas (1,287 cases to date this year), Pennsylvania (1,428 cases) and Colorado (897 cases, though they averaged 158 over the past four years) are among other states with personal belief exemptions (though the Texas one has significant restrictions and hoops to jump through). But it’s clear the decreased effectiveness of the vaccine is playing the biggest role, especially in places like Iowa (1,168 cases) and New York (2,107), neither of which offer personal belief exemptions.
Again, though, a less effective vaccine does not mean a worthless vaccine. It still offers 85 percent protection when you get the shot or the booster, and even as it loses some effectiveness as the years go by, you’re far less likely to have a severe case if you do get the disease. And you’re protecting those around you, including the babies who have only been here a few months and are the most susceptible to catching and dying from the disease.
Bottom line — it’s worth it to get the shot, and to make sure your kids do too.
Opinions expressed in this article do not either necessarily reflect or conflict with those of the DXS editorial team or contributors.
[Tara Haelle (www.tarahaelle.com) is a health and science writer and a photojournalist based in Peoria, IL after years as a Texan, where she earned her undergraduate degrees and MA in journalism at UT-Austin. She’s the mental health editor for dailyRx.com in addition to reporting on pediatrics, vaccines, sleep, parenting, prenatal care and obesity. Her blog, Red Wine & Apple Sauce, focuses on health and science news for moms, and you can follow her on Twitter at @health_reporter and @tarasue. She’s also swum with 9 different species of sharks, climbed Kilimanjaro and backpacked in over 40 countries, but that was in the years of B.C. (Before Children). She finds that two-year-olds are tougher to tussle with than tiger sharks.]
Imagine if there was a vaccine that could prevent cancer. Everyone would want it, right?
Surprisingly, no. There IS a vaccine to prevent cervical cancer, which, according to the CDC, affects about 12,000 women every year. Unlike most cancers, cervical cancer is caused by a sexually transmitted virus, Human Papillomavirus, also known as HPV. The virus can cause abnormal cell growth in the cervix, which can turn cancerous. The vaccine, approved in 2006, works against many common strains of HPV.
The vaccine is recommended for girls ages 11-12, and also provided to women up through their early twenties. The goal is to protect girls long before they are ever sexually active, so that they never contract HPV in the first place. As of 2011, the vaccine is also recommended for adolescent boys.
Contracting HPV is so common that more than half of all sexually active men and women in the United States will become infected with HPV at some point in their lives. According to a CDC factsheet on the HPV vaccine, “about 20 million Americans are currently affected, and 6 million more are infected every year.” In most people, HPV infections never lead to symptoms but the virus can cause development of cervical cancer and, more rarely, cancers of the vagina and anus, as well as genital warts. Furthermore, men can develop cancer from HPV. The virus is transmitted through skin to skin contact, which reduces the efficacy of condoms at preventing the spread of this disease.
Yet, despite the dangers associated with HPV, only 33.9% of American girls, ages 13-17, reported to the CDC in 2010 that they had been fully vaccinated (3 doses) against HPV. When I mapped the state by state rates of vaccination, I found a dramatic distribution, from only 19% of girls in Idaho to nearly 60% in South Dakota and Rhode Island.
Map created by Kate Prengaman
Much of the resistance to vaccinating adolescent girls against cancer-causing HPV comes from many people who are uncomfortable with or resistant to the fact that adolescent girls will grow up and have sex. I expected to see a strong correlation between states with Abstinence-only sex education and low vaccination rates, but the pattern in the map is weaker than I had anticipated. I also considered that the cost of the vaccines might play a role, although if they are not covered by a family’s health insurance, there are federal programs in place to subsidize the cost. There’s also some correlation there, but again, not as strong as you see, for example, when mapping teenage birthrates.
Map created by Kate Prengaman
Clearly, the pink map, lovely as it is, does not provide an answer for why more adolescent girls are not receiving the HPV vaccine. There is an unfortunate anti-vaccination movement in this country, with people choosing not to protect their kids from dangerous diseases because of unfounded fears that vaccines can cause autism, among other things. Last fall, Michelle Bachmann even used a presidential debate to stir up more fears that the HPV vaccines could cause mental disabilities, a enormous error that the medical community quickly tried to correct.
The truth is that these vaccines are safe. The truth is that HPV is really common, and it can cause cancer, and if you ever have sex, you have a good chance of getting it. Why aren’t more parents of adolescents taking the lead on protecting their kids’ future health? If you have any ideas for other factors that might explain the patterns of vaccination, let me know in the comments and I will try adding to my map. Thanks!
About the guest author:
Kate Prengaman is a science writer and outdoor enthusiast currently based in Madison, WI. Formerly a botanist, Kate is pursuing her masters in science journalism at UW, reading and writing as much as possible. She loves talking to people, telling stories, finding adventures, geeking out over wildflowers, and eating delicious things. She blogs at Xylem.
It could be Andrew Wakefield or a brain-hijacking microbe.
by Meredith Swett Walker
I’m a scientist, but I’ve learned that when we become parents, paranoia can trump the powers of rational analysis I’ve so carefully nurtured and developed. For some parents, media-whipped fears about vaccines take front and center in the anxiety lineup. For me, a brain-infecting microbe that makes mice hang around cats is at the top of my parenting paranoia list.
Parenting requires making many, many choices. Some seem inconsequential, like whether your child will wear overalls or sweatpants, pigtails or a pixie cut. But other choices have to do with health issues such as circumcision, immunization, and breast milk vs. formula – just a few in an endless list. For geeks like me, the first impulse is to research each issue, make a choice, and prepare an argument for anyone who questions the decision (and believe me, someone will.) My response usually goes something like this: “Well, recent studies have shown that yada yada yada…” Then I pat myself on the back for being so informed and making such a well-reasoned decision.
My process ran into trouble, though, when my relationship with a university and its online library access ended. What happens when you can’t get your hands on peer-reviewed scientific journal articles? One consolation should be that we live in the “Information Age.” Surely, Google, a fast internet connection, and an overwhelming flood of information should lead to what we need to make well-reasoned, science-based parenting choices. Surely.
Maybe not. A friend recently shared with me an article from the open-access (i.e., free) online journal PLoS: “Why Most Biomedical Findings Echoed by Newspapers Turn Out to be False: The Case of Attention Deficit Hyperactivity Disorder.” The gist is that the news media preferentially cover initial findings described in the most prominent scientific journals. The key word there is initial. No initial result is going to be the final word in science, and all results require confirmation from other researchers repeating or extending the experiments. Sadly, in practice, many of the follow-up studies don’t get published in the most prominent journals because they are not “a big scoop.” Yet they often show that the initial, Big Headline Finding was overblown or even incorrect.
That brings me to an example that really pushes my buttons — childhood immunizations. In 1998, Andrew Wakefield and colleagues published a study in the prominent British medical journal the Lancet. The paper examined a hypothesized association between the MMR (measles, mumps, rubella) vaccine and autism, but the authors used fairly moderate language in their conclusions. But then, Wakefield participated in a press conference about the paper and asserted in much stronger language that the MMR combined vaccine and autism were linked and that parents should turn to single shots for measles, mumps, and rubella. The news media ate it up.
The scientific community immediately pointed out a number of glaring flaws in the study, and subsequent investigations over the next decade failed to reproduce or confirm the results. But it was too late. The popular media and celebrities like Jenny McCarthy had already done the damage. Parents were terrified, vaccination rates dropped, and deadly measles and whooping cough outbreaks starting cropping up.
Yes, the news media covered subsequent studies reporting no link between vaccines and autism, but let’s face it: Science is slow, and news is fast. In the interval, scary information takes root. The Lancet retracted the article 12 years after its publication, and in 2011, British investigative journalist Brian Deer demonstrated that Wakefield actively falsified data. Still, to this day, vaccination rates have not fully recovered, and many parents remain misinformed and concerned about vaccinating their children. Indeed, the Wakefield debacle has been directly blamed for a huge and ongoing measles outbreak in Wales.
I could haz Toxoplasmodium in my poop, so be careful.
Admittedly, the MMR case is an extreme example but also a good one of how a single initial study and the ensuing media hysteria can have a huge effect on parents — and on children’s health.
And we all have our trigger points for fear. One (of the many) things in our family tree is schizophrenia. A member of our extended family developed schizophrenia as an adolescent and has never recovered. Schizophrenia can run in families, so my two children have up to a 4% chance of developing this disorder compared to the 1.1% chance of someone without close relatives who have it.
So along comes my March 2012 issue of The Atlantic featuring “How Your Cat Is Making You Crazy” by Kathleen MacAuliffe. I would have found this article fascinating even if schizophrenia weren’t a concern. Its subject is a parasite called Toxoplasmosis gondii, which usually cycles through two hosts: cats and rodents. Toxo, as I’ll call this beast, starts life as an egg in a cat, is pooped out, and then gets picked up by a new cat. How does it get into a new cat? Cats, unlike dogs, are pretty fastidious and don’t tend to eat or otherwise mess around with cat poop. So Toxo gets itself into a less fastidious but tasty morsel like a mouse, instead, making its way into the cat when the mouse becomes dinner.
That seems simple enough, but there’s more. Toxo infection ups the odds of a mouse–cat encounter by hijacking the mouse’s brain and changing its behavior. The mouse’s activity level increases (cats love to chase fast-moving objects), and the rodent might become less wary in exposed areas and even attracted to the smell of cats. Watch these videos, and you’ll see how the infected mice move faster and wander into unknown spaces, seemingly without fear, as you can see in this video and this one.
The trouble for humans is that we also canpick up Toxo through contact with cat poop or eating undercooked meat or unwashed veggies from a garden where cats poop. Becoming infected with Toxo during pregnancy can be very harmful to a fetus, so pregnant women have long been warned off cleaning kitty litter boxes. But healthy, non-pregnant adults infected with Toxo weren’t thought to experience any detrimental effects — until recently. According to MacAuliffe’s article, which focuses on the work of Czech biologist Jaroslav Flegr, Toxo might alter human behavior, too, in mouse-like ways, such as reducing fearfulness. In most people, these purported behavioral shifts are probably very subtle and unremarkable. But Flegr suggests that in some people, Toxo infection serves as the trigger for mental illness, including schizophrenia.
Schizophrenia likely develops because of interactions between genes and the environment. Having risk gene variants isn’t a guarantee a person will develop schizophrenia, and it can arise in people without those risk variants. The list of potential environmental triggers is long and includes childhood stress, prenatal undernutrition, drug abuse, and … infections with microbes like Toxo.
Reading this article set me off on a tear of worrying. We have a cat, but I wasn’t worried about her. She is an indoor cat (we love birds), and there is a very low incidence of Toxo infections in indoor cats. But we have outdoor cats and feral cats in our neighborhood. They sometimes hang out in our yard, where my kids like to play in the dirt and eat things out of the garden, including the dirt itself. Oh, poop.
I took to Google and researched cat traps and repellents and how to get kids to wash their hands. I laid awake at night for hours strategizing about how to keep my home and yard Toxo free. And then I realized, even if I managed to exclude all cats from my yard and the totally impossible feat of getting my children (ages 1 and 2) to wash their hands before they touched their faces or food every time, I was still doomed to failure. My kids would go to friend’s houses and play in their Toxo-infested yards. Or they might already have encountered Toxo anyway.
Toxo was something I couldn’t control, and I needed to let it go. At our next check-up, I talked to our pediatrician about it, who had never heard about the potential Toxo–schizophrenia link. She graciously concealed her “Oh, Lord, another parent with a loony theory” reaction and calmed me down. As she put it, my only real option to prevent Toxo infection was to never allow my children to play outdoors or in the dirt, and the detrimental effects of that were likely far greater than the risk of schizophrenia, Toxo or no Toxo.
And she also reminded me of what I already knew and should have remembered: These findings about Toxo are initial findings.
As a scientist, I know that the schizophrenia–Toxo link needs more study. A lot more study. As a parent, well … yeah. I still worry, and no lack of replication or confirmation is likely to stop me.