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- Knowledgebase: Immunization Questions
- Questions about immunizations, side effects, and not vaccinating.
- 5. Vaccines Under Fire: The Importance of Perspective - Top
- Vaccines Under Fire:
The Importance of Perspective
PEDIATRIC ANNALS 30:7/lULY 2001
Gary S. Marshall, MD
A few years ago, my family and I spent the weekend at a quaint southern Indiana bed and breakfast. In the dining room hung the Victorian era portrait of a girl wearing a long, lacy, pink dress, holding one of those paper fans. The plaque on the frame gave her name, her family lineage, and the caption, "Died of diphtheria, 1887." Terrified, my kids asked whether children still died of diphtheria. I said no, and the fear melted from their faces.
My grandparents told of long, hot Philadelphia summers when children were barred from public swimming pools for fear they would acquire poliomyelitis. Even water fountains were off limits. They would not have believed that the last case of wild-type polio in the Western Hemisphere would occur long before the end of the century.
In 1954, 1.8 million children participated in the largest medical experiment ever conducted. They got lollipops and Polio Pioneer buttons; some received polio vaccine and some received placebo. The vaccine worked, the nation embraced immunization, and infantile paralysis took its long agonal breath.
These days, I often think we have entered the alternate universe—you know, the one where Spock is emotional and Kirk is logical. Irony pervades that universe, - as it does post-modern America, where, in the face of unprecedented achievements in infectious disease prevention, pediatricians fight an uphill battle to convince parents that vaccines are vital. How did we get here? Through the wormhole of our successes.
FROM FEAR OF DISEASE TO FEAR OF VACCINES
Because disease is rare, fear of disease has been replaced by fear of vaccines. Sure, there are other factors: the ease with which misinformation is disseminated on the Internet, distrust of authority, the anti-science counterculture, libertarian philosophy, and litigiousness. But the simple truth is that most parents have not spent a night in the pediatric intensive care unit because their child had Haemophilus influenzue type b meningitis. Many would be surprised to learn that infants can cough themselves to death from pertussis, or that group A streptococcus can liquefy flesh in the child with varicella (varicella, in
many eyes, remains a benign childhood right of passage).
Parents may not fully appreciate (in fact, there are those who would try to convince them otherwise) that without concerted immunologic pressure at the population level, horrible, forgotten diseases may return to claim their children. There is empirical evidence of this from several countries (eg, fear of pertussis vaccine in the 1970s led to decreased vaccine use, epidemic disease, and senseless deaths).2
CHALLENGES TO VACCINE SAFETY Challenges to vaccination are everywhere—on television, in magazines, and at the grocery store checkout line. Parents hear that the diphtheria, tetanus, and pertussis combination vaccine causes sudden infant death syndrome; that hepatitis B vaccine causes multiple sclerosis; that measles-mumps-rubella vaccine causes autism; that vaccination in early infancy causes diabetes; that thimerosal has caused neuro-developmental problems; that oral poliovirus vaccine was the cause of acquired immunodeficiency syndrome (AIDS); that the immune system is weakened by vaccines; and that varicella vaccine is made in aborted fetuses (the virus is grown in cell lines that have been perpetuated from one 14-week fetus since 1966).
There has been testimony on Capitol Hill that asthma is increasing because kids get too many shots.3 A book even links social violence to vaccinations.4 Credible scientific studies do not support these safety claims,5 but parents may not have the ability to distinguish good science from bad science.
This is where we come in. We are trusted, and we have the expertise to critically evaluate complex information and translate it into simple recommendations. Parents should be empowered to make informed decisions, but when you come down to it, most parents want to know what their pediatrician would do for his or her own children. Tell them. Look at it this way. You may read about water heaters, but ultimately you value the opinion of a trusted plumber.
THE VACCINE SAFETY NET
Parents may also not appreciate how much time and effort goes into developing vaccines and establishing their safety and efficacy. Varicella vaccine had a gestational period of more than 20 years.6 The tetravalent rhesus rotavirus vaccine was given to more than 10,000 children before licensure, and no statistically significant association with intussusception was detected.7 It took 11/2 million children receiving the vaccine after licensure before a defini
live association could be confirmed.
This association was not easily detected because the incidence of intussusception attributable to rotavirus vaccines was, by the way, less than the natural incidence. The alarm, consisting of reports to the Vaccine Adverse Event Reporting System (VAERS), sounded loudly and officials moved rapidly to investigate. VAERS9 and the Vaccine Safety DataLink projects are examples of how vaccine protest has been beneficial—these systems lower the threshold for detection of adverse events, and vaccine protest encouraged their development. Parents should be told about these mechanisms in place to protect their children from harm.
Ultimately, parents want to do what is right for their children. A few, I believe, forget that we are on their side. They have become caught up in Internetfueled speculation, some of which borders on conspiracy theory (one is that the Centers for Disease Control and Prevention is in cahoots with drug companies to cover up vaccine dangers). It is difficult to know how to respond to allegations like this, but no parent's concerns should be summarily or paternalistically dismissed.
Having said this, I think that pediatricians should approach the issues from a position of vaccine advocacy, knowing that the overall benefits of vaccines far outweigh the risks. At the same time, we must acknowledge that vaccines are not 100% safe, that minor reactions are to be expected, and that serious
adverse events are rare but possible. This needs to be seen in perspective: nothing in medicine is 100% risk-free, not even the amoxicillin prescriptions we readily dispense.
After a generation of Americans received oral poliovirus vaccine, public swimming pools became filled with happy children once again. However, oral poliovirus vaccine caused one case of vaccine-associated polio for every 2.4 million doses that were distributed. This risk was tolerable at a time when natural disease was more of a threat. But with the elimination of circulating wild-type disease, this danger gradually disappeared. Oral poliovirus vaccine was therefore retired in favor of inactived poliovirus vaccine.ll The balance between public health benefit and individual risk had changed, and vaccine policy changed accordingly. This is how it should and does work, and we need to help parents know and understand this.
REFERENCES
1. Lambert SM, Markel H. Making history: Thomas Francis, Jr., MD, and the 1954 Salk Poliomyelitis Vaccine Field Trial. Arch Pediatr Adolesc Med. 2000;154:512-517.
Gangarosa EJ, Galazka AM, Wolfe CR, et al. Impact of anti-vaccine movements on pertussis control: the untold story Lancet. 1998;351:356361.
3. Orient JM. Statement before House Committee on Government Reform and Oversight: August 3,1999.
4. Coulter HL. Vaccination, Social Violence, and Criminality: The Medical Assault on the American Brain. Berkeley, CA: North Atlantic Books; 1990.
5. Marshall GS, Gellin BG. Challenges to vaccine safety Family Practice Clinics of North America. In press.
- Updated: July 11, 2001
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