Addressing Your Patients’ Vaccine Doubts: Point-Counterpoint, Part 1
Doubt can only be removed by action.
—Johann Wolfgang von Goethe
Health care providers encounter a myriad of anti-vaccine claims, some of which we are readily equipped to discuss (“The flu shot causes the flu,” for example). Yet, others seem so far out in left field (such as, the “formaldehyde and aluminum in vaccines cause cancer” assertion) that we are sometimes caught off guard and may be unprepared to discuss the research and data that support the effectiveness and safety of our immunizations. Sometimes our patients’ anti-vaccine claims represent a fundamental misunderstanding of how vaccines work. Sometimes they are based on erroneous interpretation of science and statistics. And sometimes they play into the fears of parents or of laypeople trying to make sense of complicated and often confusing research. It is our job to educate our patients with the facts that justify our recommendations and to set our patients’ minds at ease. (See Appendix B: Fast Facts about Vaccines for Patients and Clinic Staff.)
But when does the average clinician have time to do all the investigation necessary to provide counterarguments to their patients’ many assertions? We spend long hours taking care of patients, sometimes barely having time for family, friends, and self-care. The task of researching the science and data to counter arguments to anti-vaccine claims can seem daunting. Below you will find the most commonly heard anti-vaccine assertions (and some not so commonly heard) and the information you will need to counter them. Chapter 10 will continue the discussion and address those concerns that are specific to certain groups (religious groups, children, pregnant women, and immune-suppressed patients). Finally, chapter 11 will look at the two most “controversial” vaccines—influenza and HPV. These chapters are laid out in a question and answer or point-counterpoint format that you can use to provide quick and easy education to your patients.
1. How do vaccines even work?
Our bodies attempt to protect us from harm by mounting an immune response when exposed to foreign proteins (such as viruses and bacteria). Through vaccination, we harness the benefit of this response by
exposing the body to killed or weakened viral or bacterial proteins in a safe and controlled manner. Our body then develops memory cells (anti-bodies), which live on for years and are quickly mobilized to protect us in the event of future exposure to that same virus or bacterium. To draw an analogy to war, instead of a surprise attack where all of our “troops” are ill-prepared for the onslaught and we suffer large losses in the battle; through vaccination, we are now equipped with weapons to defend ourselves, and our bodies are prepared to successfully fight off an attack.1 (See Appendix C: Vaccine Topics Explained for a video explaining how our immune systems respond to vaccines).
2. If vaccines are so beneficial, why don’t we have vaccines against the common cold? Colds make more people sick each year than tetanus and whooping cough do.
The common cold is, well, common, and it certainly can make us feel miserable, but there are several reasons why we don’t have vaccines against cold viruses. First, it is extremely costly to produce a vaccine—costing billions of dollars (see chapter 5 for more discussion of this topic). Second, it is not an easy process. It takes 10 to 15 years on average to develop and produce a vaccine. Third, and perhaps most importantly, cold viruses don’t typically land people in the hospital and cause serious health consequences or death. We immunize against viruses and bacteria that have the potential to be severely damaging and deadly.
3. What are the different types of vaccines? What is the difference between a “killed virus vaccine” and a “live-attenuated virus vaccine” (Table 9.1)?
There are generally considered to be four different types of vaccines. We can subdivide these into those vaccines that are safe for all (inactivated/killed, subunit, and toxoid vaccines) and those that are not safe for people with a weakened immune system (live-attenuated vaccines).
Live-attenuated vaccines—These vaccines contain live viruses or bacteria that have been weakened. These are most similar to a natural infection and provide the longest immunity. Because they contain the live germ, they cannot be used in people who have a compromised immune system (pregnant women, newborns, AIDS patients, or patients on chemotherapy or other types of immuno-suppression, for example). Another challenge with this type of vaccine is that it also has to be kept cool. This renders them difficult to transport and use in parts of the world where access to refrigeration is scarce.
Inactivated/killed virus vaccines—These vaccines contain viruses or bacteria that have been inactivated or killed. There is no live germ present in these vaccines, therefore they cannot induce the infection against which they are meant to protect. Their immunogenicity (ability to induce an immune response) is less than a live-attenuated vaccine, so they may require boosters to provide life-long immunity.
Subunit, recombinant, polysaccharide, and conjugate vaccines—These use pieces of the virus or bacterium (such as sugars, proteins, or the casing around the germ, called a capsid) to induce an immune response. These also are safe for all but may need boosters to maintain immunity.
Toxoid vaccines—These vaccines don’t use the virus or bacterium itself, but instead use the toxin that is produced by the virus or bacterium to induce an immune response. Toxoid vaccines are also safe for everyone and need boosters to provide lasting immune protection.
TABLE 9.1 Types of Vaccines | ||||||||||||||||||||||||||||||||||||||||||||
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4. What about the aluminum in vaccines. Isn’t that toxic?
Aluminum is used as an adjuvant to boost the immune response to vaccines. Aluminum is used only in inactivated, subunit, and toxoid vaccines, not in live-attenuated vaccines. The Agency for Toxic Substances and Disease Registry (ATSDR) monitors minimum risk levels (MRLs)—levels below which we will not see any harm—of aluminum and other compounds in vaccines. The amount of aluminum in vaccines is definitively below MRLs (1.0 mg/kg/d).2
Aluminum is the most abundant element in the earth’s crust. In nature, it is found most commonly in combination with other elements in the form of potassium aluminum sulfate and aluminum oxide.3 Aluminum is extracted from these compounds and placed into products we use every day (pots, pans, aluminum foil, seasonings, cereals, baby formula, paints, fuels, antiperspirants, etc.). It also leaches in small amounts from the earth’s surface into our food and water supply. We are exposed to and consume more aluminum (the average adult consumes 7-9 mg of aluminum per day)4 than we are ever administered in any series of vaccines. Babies, for example, consume more aluminum from breast milk or formula in the first 6 months of life than they receive from all the immunizations given in that same time period (Box 9.1).
Box 9.1 Facts About Aluminum in Vaccines
Infants get about 4.4 mg of aluminum in the vaccines given in the first 6 months of life.
Infants get more than that in their diets during the first 6 months of life.
Breast milk—˜ 7 mg/6 mo
Formula—˜ 38 mg/6 mo
Soy formula—˜117 mg/6 mo5
If we take the weight of an average 6 month old (around 16.5 pounds—a little less for girls and a little more for boys), the amount of aluminum that they could safely receive (calculated using the MRL) would be approximately 7.5 mg/d. If we were to give every vaccine recommended at the 6-month well-child check (Hep B, rotavirus, DTaP, Hib, PCV13, IPV, and influenza),6 we would only be giving 1.4 mg of aluminum, much below the allowable MRL.5 Note that some children may receive fewer vaccines at 6 months as there is some flexibility in dosing per the Centers for Disease Control and Prevention (CDC) vaccine schedule. Also note that vaccines given in combination form often have even less aluminum per dose than if given separately—yet another reason not to space out immunizations (Box 9.2).
Box 9.2 Did You Know?
Children ages 6 months through 8 years, who have never had an influenza immunization, need to begin with the two-dose series. This is also true for children who only ever received the first of the two-dose series. These first two influenza vaccines should be administered at least 28 days apart. Any person who has already received their first two-dose series, or is at the age of 9 years or older, only needs one dose per flu season going forward. The reason for the two-dose series is that the first dose, given to those ages 6 months through 8 years, is not likely to cause a full immune response by itself. It “primes” the immune system. The second dose is where we get a more robust immune response. By the age of 9 years, however, we are likely to have already come in contact with an influenza infection naturally and have developed some aspect of immune memory. After the age of 9 years, one dose of influenza vaccine is, therefore, all that is needed to mount a full response to the vaccine.7,8
5. I heard there is formaldehyde in vaccines. Doesn’t formaldehyde cause cancer?
Formaldehyde is used in the vaccine production process to inactivate viruses and to render bacterial toxins no longer toxic. It is diluted during manufacturing to the degree that there is only a minuscule amount remaining in some vaccines.
Formaldehyde is listed by the ATSDR as a possible human carcinogen but this requires much higher levels of exposure than what is present in vaccines, and toxicity is typically greatest through inhalation. The ATSDR lists MRLs (levels below which are considered to be nontoxic) for
formaldehyde as 0.3 mg/kg/d on an intermittent basis.2 Considering our same 6-month-old baby, weighing an average of 16.5 pounds, he or she could safely be exposed to 2.25 mg of formaldehyde per day. In all of the shots recommended at the 6-month checkup (if we include influenza), there is only approximately 0.2 mg given. Again, much below the MRL.
What is not commonly understood by the general public is that our bodies require formaldehyde for cellular function. Our bodies actually make their own formaldehyde to aid in the production of amino acids, the building blocks of proteins, and in the metabolism of some fats. Our bodies contain approximately 2.6 mg of formaldehyde per liter of blood. Given that humans have around 5 liters of blood, we have about 13 mg of formaldehyde circulating in our systems at any given time.9 Even the average newborn, weighing only 6 to 8 pounds, has approximately 50 to 70 times more formaldehyde in his or her system10 than the newborn would be exposed to in any one vaccine or series of vaccines.
In addition to the formaldehyde made by our own bodies, we are exposed to formaldehyde through our environment as well. It is in products that we use every day, such as household cleaners and building materials, and in the foods that we eat.
Whether it is with aluminum or formaldehyde or any other ingredient in vaccines, what we need to remember is that anything in too great a quantity can be toxic. Even water can be harmful to our health, diluting the salts in our body and causing heart arrhythmias, weakness, and confusion if we drink too much of it. As the saying goes, “The dose makes the poison,” and the doses of these components of vaccines are significantly below levels that should worry us (see chapter 12 for a more detailed discussion regarding vaccine ingredients).
6. There’s squalene in vaccines. Wasn’t that given to soldiers in the anthrax vaccine and is the cause of Gulf War Syndrome?
We have Joseph Mercola to thank for espousing this bit of misleading information. In his article titled “Squalene: The Swine Flu’s Dirty Little Secret,” he lays out these claims and others that are completely unfounded.
First, squalene is a naturally occurring molecule found in plants, animals, and humans. In humans, it is produced in the liver and circulates in the bloodstream. It is felt to have antioxidant properties when consumed in foods, such as olive oil and fish oils.
Second, there is no squalene in most US-licensed vaccines. Only the influenza vaccine, Fluad, licensed for use in patients older than 65 years of age, contains squalene. When combined with surfactants (which help particles in a liquid remain in suspension), it works as an adjuvant to boost the immune response in this vaccine.
Third, according to the World Health Organization (WHO), squalene was neither added to nor used in the manufacturing process of the anthrax vaccine that was given to Gulf War military.11,12
Lastly, studies looking at the levels of antisqualene antibodies in Gulf War veterans showed no elevation of antibody levels beyond those in the baseline population. They also showed no increase in antibody levels generally in patients vaccinated with squalene-containing vaccines versus nonimmunized people.13,14
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