Vaccine Concerns in Specific Populations: Point-Counterpoint, Part 2
Don’t believe every worried thought you have. Worried thoughts are notoriously inaccurate.
—Renee Jain
In the last chapter, we discussed general questions and concerns that you may hear about vaccines and how to reply to or counter them. In this chapter, we will continue the discussion but look at questions that specifically relate to certain groups of patients or segments of the population. First, we will delve into the common childhood-specific vaccine claims you may encounter as well as those that relate to immunization during pregnancy. Next, we will look at the religious objections that we hear regarding vaccines and why most of them, based on the tenets of the world’s leading religions, are unfounded. Finally, the chapter will speak to some of the specific issues surrounding vaccination of immune-compromised patients.
As parents, or prospective parents, we worry. We are really good at it. It is a skill that grows and gestates right along with the growing fetus. Worry isn’t all bad though. It does serve some purpose. It keeps us vigilant and cautious so that we may protect the new and delicate life whose care has been entrusted to us. But, for some, worry and fear can become paralyzing and keep us from making decisions that are best for our littlest loved ones. The anti-vaccine movement does a brilliant job of playing on our parental worries. If we allow ourselves to fall prey to anti-vaccine fearmongering, we can inadvertently increase, not decrease, the risk to our children. The following are some of the most common concerns that you will hear during your vaccine counseling discussions and the information you need to help reassure parents that vaccines are safe, effective, and are truly one of the best things we can do to protect our children (also see Appendix B: Fast Facts about Vaccines for Patients and Clinic Staff for a helpful patient handout addressing many common vaccine-related concerns).
SPECIFIC CONCERNS RELATED TO CHILDHOOD VACCINATIONS
1. I’ve heard that vaccines cause autism. Autism is a developmental disorder that negatively affects a child’s ability to communicate and interact with others. Features of autism often include repetitive behaviors and obsessive interests. Referred to as Autism Spectrum Disorder (ASD), it has a broad range and severity of symptoms that often begin to be recognized by parents and clinicians when the child is around the age of 2 to 3 years, but sometimes not until the child is of school-age.
Although physicians and scientists have yet to discover the exact causes of autism, we can say with confidence that there is no one event or one cause, such as vaccines. There are likely multiple factors at play, such as older maternal age, the in utero environment, nutrition, and genetics.
In review of home movies from infancy in children who were later diagnosed with ASD, we know that symptoms of autism often developed many months before administration of the measles, mumps, and rubella (MMR) vaccine (typically given at 12-15 months).1,2
As we learned in the last chapter, in discussion of MTHFR gene mutations, nutritional status and lack of adequate folate levels may play a role.
We know that there are higher rates of ASD in identical twins (77% concordance in identical twin boys and 50% in identical twin girls) than in fraternal twins (31% in male fraternal twins, 36% in female fraternal twins, 5.3% for female twin of affected male twin, and 50% for male twin of affected female twin).3,4
We know that there are higher rates of autism in siblings, regardless of vaccination status.5 A Kaiser Family Foundation study showed that children with an older sibling carrying the diagnosis of ASD were approximately 14 times more likely to be diagnosed with ASD themselves.6
We also know that autism affects boys four times more often than girls.7
All of these findings suggest a strong genetic link.
As discussed in chapter 8, the largest setback to vaccination efforts in recent history was the 1998 study by Andrew Wakefield suggesting that vaccination with the MMR vaccine was linked to the development of autism. Wakefield’s study involved only 12 children. Subsequent studies involving hundreds of thousands of children have found no such relationship. There is even some data to suggest that MMR vaccination may provide a protective benefit against ASD.8,9 Wakefield’s claims have been debunked numerous times over. His paper was found to be fraudulent, and he was stripped of his medical license for falsifying data. However, the damage to vaccination efforts was done, and this claim persists today, despite much evidence to the contrary (See Appendix E: Journal Articles Addressing Specific Vaccine Concerns for a list of studies you can recommend to your patients that disprove any link between vaccines and autism).
Regarding the specific concern that exposure to mercury increases the risk of autism, it is interesting to note that rates of autism have actually
increased since thimerosal was removed from all US-licensed vaccines in 2001. As of writing this book, the CDC’s Autism and Developmental Disabilities Monitoring Network now estimates that 1 in 59 children has been identified as having ASD.10 If there were a true association between the two, we would have expected the opposite to occur. The rates of autism should have declined as children were no longer exposed to ethyl mercury in vaccines, but they didn’t.11,12,13
Much to pediatricians’ and family physicians’ dismay, the MMR-autism claim is not the only vaccine-autism assertion that exists. The anti-vaccine community casts their net wide and also asserts the following: The mercury in vaccines causes autism, the aluminum and formaldehyde in vaccines cause autism, and the sheer number of vaccines that we give children causes autism. Yet, in study after study looking to investigate these concerns, none of this has proven to be true.8,14
2. Aren’t all the vaccines they recommend for kids going to overwhelm or weaken their immune systems?
Studies looking for a link between vaccination, or the number of viral and bacterial proteins in a series of vaccines and the development of autism and other health concerns, show no increased risk of autism15; no increased risk of autoimmune disease16; no increased risk of other non-vaccine targeted infections17; no increased risk of childhood cancer, and in fact, show a possible protective effect on rates of childhood leukemia.18
Kids are exposed to more proteins on a daily basis (crawling around on the floor, constantly sticking their hands in their mouths, sharing germs with kids at school or day care) than they are ever exposed to in a series of vaccines. Moreover, the infant immune system has a remarkably large capacity to respond to antigenic challenges. Modeling would suggest that an infant’s immune system could actually handle up to 10,000 vaccines given at once. It also indicates that if 11 vaccines were given to an infant all at one time, only 0.1% of their immune system would be “used up.”19 An infant’s immune system is not overwhelmed or weakened by the current immunizations recommended.
Exposure to environmental proteins (antigens), and to those in vaccines, serves to boost an infant’s immune system and to keep the infant safer in the long run. For example, studies show that children who are exposed to animal dander in their younger years have lower rates of asthma, eczema, and allergies.20,21 Moreover, kids who have been vaccinated with a measles-containing vaccine show a lower rate of all-cause mortality than those who have not been vaccinated.22
Thanks to advances in vaccine production, the immunologic load in today’s vaccines is even less than it used to be. The 14 vaccines given today contain fewer than 200 bacterial and viral proteins or polysaccharides, compared with greater than 3000 of these immunologic components in the 7 vaccines administered in 1980.23
Vaccines continue to be perfected. With scientific advancement and better understanding of how to “train the immune system” to defend against disease, vaccines are becoming more precise. When the pertussis (whooping cough) vaccine was first developed in the 1930s, for example, it contained approximately 3000 bacterial proteins. Now, it contains two to five.23,24
3. That’s so many pokes at one time. Can’t we just space out the shots? What about the Dr. Sears schedule for vaccines?
There are multiple ways in which The Vaccine Book: Making the Right Decision for Your Child, written by Dr. Robert Sears and published in 2007, misrepresents vaccine science and leads patients astray in making their vaccination decisions.25,26
Most important to note is that Dr. Sears’ Alternative Vaccine Schedule, in seeking to make it so that children receive no more than two shots at one visit, would require doctor’s visits at 2, 3, 4, 5, 6, 7, 9, 12, 15, 18, 21, and 24 months and at 2.5, 3, 3.5, 4, 5, and 6 years old.
This significantly increases the number of office visits, the number of injections kids receive, and raises the age at which vaccines are given. The result is an increase in the risk of illness outbreaks and a decrease in the likelihood that parents will get their kids back to the office to complete the full series.
If parents are concerned about the exposure to adjuvants or formaldehyde in vaccines (not that they should be, as discussed in the last chapter), spacing out the vaccines into individual shots has the potential to increase the exposure to those substances (for example, aluminum in Dtap is <0.33-0.625 mg/dose and in Hib is 0.225 mg/dose for a maximum cumulative dose of 0.85 mg). Whereas, using the combination vaccine of Dtap/IPV/Hib (given all at one time, in one injection) exposes a child to only 0.33 mg/dose.27
4. Kids produce a better immune response to the real thing. I prefer for my child to get chickenpox (or any other vaccine-preventable illness) naturally.
Although the antibody response may be more vigorous following a “natural” infection than that induced by a vaccine, the “natural” infection carries with it significantly greater risk to life and health. As stated previously, we don’t make vaccines against benign diseases. We vaccinate against viral and bacterial infections that have the potential to kill or seriously harm.
Although most children will recover from chickenpox without incident, some children will develop pneumonia or encephalitis (inflammation of the brain that can cause permanent brain damage). Some will die from the illness. A natural infection from chickenpox also puts people at much higher risk of a devastatingly painful condition in later years called shingles.
For measles, the statistics regarding “natural” infection are even worse. Of those infected, 1 in 4 will be hospitalized; 1 in 1000 will develop encephalitis; and 1 to 2 in 1000 will die from the infection. Even if a child recovers without incident, they can still develop subacute sclerosing panencephalitis years later. Acquiring an infection naturally can put children at significant risk. (See Appendix C: Vaccine Topics Explained for a video about the devastating effects of subacute sclerosing panencephalitis.)
Natural infection from tetanus often means death. Natural infection from meningococcal meningitis results in high rates of seizures, loss of limbs, and death. Natural infection from human papillomavirus (HPV) can result in cancer. Natural is not always better.
5. Why do kids need to be vaccinated against hepatitis B at such a young age if it is a sexually transmitted or blood transmitted infection?
The hepatitis B virus (HBV) is an infection that can be transmitted via blood or body fluids (including saliva, tears, seminal fluid, and vaginal secretions).28 Although certain factors (such as intravenous drug use, unprotected sex with multiple partners, and working in a medical field where accidental blood exposure can occur) may certainly put one at greater risk for contracting HBV, it can still be acquired without risky activity. In fact, initial efforts at identifying “at risk” groups and targeting vaccination to those individuals were unsuccessful at limiting rates of HBV infection.29 It wasn’t until we started vaccinating the general pediatric population that we began to see a decrease in rates of HBV infection (Figure 10.1).
A baby can acquire HBV by being born to a mother who is carrying the virus. A child could be bitten by another child who is carrying the virus. A teen could decide to use her friend’s razor to shave her legs at a sleep over and contract the virus. None of these things seem inherently risky, but any activity where the skin is broken and permits exposure to infected blood or body fluids could result in virus transmission.
FIGURE 10.1 Graph showing impact when hepatitis B vaccine became available but was used only in “at risk” populations versus dramatic improvement seen when the vaccine was added to the infant schedule recommended for all children. (Adapted from Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67(No. RR-1):1-31. doi:10.15585/mmwr.rr6701a1.)
HBV increases the risk of cirrhosis and liver cancer. This is one of only two cancer-prevention vaccines that we have, the other being the HPV vaccine. None of us like to think that our children will engage in risky behavior, but we know that many kids will make choices in their teen years that they might not make as wiser adults. Moreover, these decisions may have unintended consequences. HBV vaccination is one very important way that we can protect our kids from one such potentially lifelong and deadly consequence.
Finally, and perhaps most importantly, we know that kids who contract HBV at a young age are much more susceptible to the lasting effects of HBV infection. Babies don’t fight off the virus as well as older individuals. 9 out of 10 babies who become infected in their first year will develop chronic HBV, staying infected for life. Up to 25% of children who become infected during the first 5 years of life will die an earlier death from HBV-related liver disease, including liver failure or liver cancer.28,30
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