I am one of the increasingly rare old-timers who lived during the pre-vaccination era,
when epidemics of dread diseases left millions of Americans living on the edge of panic.
The worst of many, the Great Spanish Flu epidemic of 1918-1919, was before my time, but
stories about it were still common when I was growing up in Rochester, N.Y. Between
the autumn of 1918 and the spring of 1919, an estimated 20 million to 40 million people
died worldwide from influenza. In the United States, about a quarter of the entire
population became ill, and more were killed by the flu that would fall during World War I,
World War II, the Korean War and the Vietnam War combined.
In cities like Boston and Philadelphia, people were dying so quickly and in such large
numbers that undertakers ran out of coffins, streetcars were converted to hearses and mass
graves had to be dug.
The afflicted turned the color of mahogany, suffocating from bloody fluid that quickly
filled their chests. Doctors and nurses knew that the patients with the most
profound color change, those whose feet had turned black, were beyond help and by-passed
them to help patients who still had a chance for recovery. It sounds callous, but it
was their only choice. Yet a simple vaccination shot - had it been available then -
would have saved many millions lives.
I am the second to the last of 13 siblings, five of whom died of vaccine-preventable
diseases in infancy.
Born to immigrant parents, I remember well my mother's account of the causes of their
deaths. Three died from "la tussa forte." "Tussa" is an
Italian word that derives from the same stem from which we get "pertussis."
Two others died from "rosolia" or measles.
Even after many years had passed, she spoke of the "morte d'angeli" - death
of her angels - with a great deal of emotion. Imagine losing not one or two or three
or even four babies - but five.
It was common in the pre-vaccine era. Like our family, many families lost several
children to these diseases.
We forget. Time blurs our memories of these common tragedies of yesteryear. I
remember, however. During the winter and spring of each year, one could hear the
whoop of pertussis in movie theaters, school assemblies and assorted gatherings. The
dreaded whooping cough. Today, few have ever heard this, and those who have, forget.
They forget infants with pertussis turn blue after agonizing coughing spell. They
forget that they get wild, frightened look in their eyes as they gasp for breadth.
They forget that adults with pertussis often cough so hard that they break ribs.
I also remember the summer outbreaks of polio, the crippled children who could no
longer walk or who walked with limb-distorted limps. I remember parents warning
their children to stay away from community pools and not to drink from garden hoses.
As a third- and fourth-year medical student, I answered the appeals of hospital
administrators who could not find the nursing staff for special duty tending to the needs
of polio patients in iron lungs. Yet now, we forget. I also can remember the
awful cases of measles my own children experienced. I remember the children with
smallpox during the years my family lived in Pakistan. I remember those who lost
their sight from lesions in their eyes. I remember those who died. Yet now, we
forget.
Coming back to the present and looking to the future, I'm happy that during my career
in public health, we've managed to quell and sometimes even squash these dread diseases.
We still have a long way to go, of course. But we can keep ourselves and our
neighbors free of most of the dread diseases by the simple act of vaccination.
Parents, especially, should follow the guidelines recommended by the American Academy
of Pediatrics and the Center for Disease Control and Prevention and have their children
take the full schedule of recommended vaccinations.
And don't let the temporary shortage of flu vaccine deter you from getting a flu shot
this year. The Spanish Flu of 1918-19 may never return, but new strains can develop
that would be just as deadly.
Originally published in the Lexington Herald Leader, a Knight Ridder publication,
Monday October 16, 2000.
Vaccines and Infectious Diseases:
Putting Risk into Perspective
National Network for Immunization
Information
Remarks By
Bruce Gellin, MD, MPH
Executive Director
National Network for Immunization Information
American Medical Association Briefing on Microbial Threats National
Press Club Washington, DC June 1, 2000
The topics we’re discussing today have several things in common.
First, they all relate to infectious diseases.
Second, they all present growing risks to health to people in the US and
around the world.
And third, they have been on the radar screen for some time but the blips
seem to be getting brighter, so they can’t be ignored any longer. It’s time to
focus and take action.
Bioterrorism, emerging infectious diseases and microbes that are resistant
to the best antibiotics and antivirals we can construct are the obvious topics
for a session like this.
Less obvious, but potentially more of a threat to the public at large are
the concerns, doubts, and misperceptions that increasing numbers of parents seem to be
having about childhood immunizations.
Should these concerns, doubts, and misperceptions be left
unaddressed,
they could translate into a decline in the public's confidence about vaccines. If, as
history has shown, a decline in public confidence leads to a decline in vaccine use, a
number of diseases that are now well under control may re-emerge.
Vaccines are the most effective public health tool ever created. Life
expectancy at birth has been extended by 30 years since 1900. And it’s estimated that
25 of those 30 years are attributable to public health advances, especially
vaccines.
We have achieved historic levels of immunization use in the community and
record low rates of vaccine-preventable diseases. As a result of our immunization policies
and practices in the U.S. we almost never see outbreaks of diseases like measles, polio,
and diphtheria. Unlike parents of
just a generation ago, today’s parents do not experience the annual summer outbreaks
of polio and the self-imposed quarantine that kept children from movie theaters, swimming
pools, water fountains, and summer camps. But because parents no longer see, and
don’t fear that their child is at risk of being infected with these serious
contagious diseases, we are risk of becoming a victim of our successful vaccination
programs.
The coverage rates tell us that at present most parents continue feel that
immunizations are the right thing for their child. At the same time, the research that the
National Network for Immunization Information (NNii) has
conducted over the past year shows that a significant minority of parents hold a number of
important misperceptions that could ultimately erode their support for immunization.
NNii conducted a series of focus groups all across the country and also
conducted a nationally-projectible survey with parents. We found that beneath the high
immunization rate, there is another story. Parents have many questions about vaccines and
our immunization policies. In addition to being unfamiliar with the diseases that vaccines
prevent, they want to know more about the vaccines. Among their many questions: How are
they
made? What are they made of? Are they as safe as they can be? Why do they contain the
components that they do (such as the mercury-containing
preservative thimerosal and an immune-stimulating adjuvant that contains
aluminum)? How are recommendations made? Who makes the recommendations?
These are all the right questions. The problem is that the system
hasn’t quite figured out how to get parents the answers they need. Parents are
searching for answers, and many are either not finding the answers, or are
getting information that’s incorrect. As a result, many parents have significant
misunderstanding about vaccines and our immunization programs and policies.
Nearly 20% of parents we surveyed did not know how – or even if --
vaccines are evaluated for safety and efficacy before they are licensed for use. They are
unaware of the long road of vaccine development – taking as many as 10-15 years to
complete the extensive laboratory work and clinical evaluations necessary to be even
considered for licensure.
One-fourth of parents we surveyed felt that their child’s immune
system could be weakened as a result of vaccination and almost as many felt that children
were getting more immunizations than are good for them.
Except for those who live in bubbles, we are continually exposed to
bacteria, viruses, allergens and foreign proteins as part of daily living. The immune
system can handle hundreds of thousands, if not millions of such challenges. For example,
depending on the particular virus, we may be exposed to up to 10 foreign proteins during a
single episode of an upper respiratory infection. A routine “strep throat” will
present between 25 and 50 foreign proteins to the immune system. Modern vaccines are made
of refined components of the organism, therefore actually present less of a challenge to
the immune system than an infection would.
Since this survey was conducted last spring, prior to the withdrawal of
the rotavirus vaccine and the discussions about further reducing exposure to
thimerosal,
the mercury-containing preservative in some vaccines that prevents contamination, it is
likely that the level of concern among parents
has only risen in the last year.
How did we get here?
The reasons why so many parents have important misunderstandings about
vaccines are complex, but there are several key elements that we can all help to fix.
First, the scientific process can be confusing to those without scientific
training. Even though the vast majority of the scientific data, and virtually all
doctors, support the fact that vaccines are safe and effective, researchers are always
looking for ways to make vaccines even safer. So, research on highly unlikely hypotheses
about side effects of vaccines – the results of which often simply prove that there
is no such relationship -- is often taken
out of context. It’s hard not to pay attention when a major network’s anchor
introduces a vaccine story on the evening news with, “We were stunned to learn that
questions have been raised about the way we vaccinate our children.” Unfortunately,
the real finding often gets lost in the hype.
Recently, there was a lot of publicity surrounding a congressional hearing
that examined the unproven hypothesis that the MMR vaccine is the “cause” of
autism. News coverage focused on stories of children who were diagnosed with autism soon
after receiving their MMR immunization, leading viewers and readers to the obvious
conclusion that there must be some relationship.
But the truth is different than it may have appeared. Because the concerns
of parents ARE taken seriously by the medical community, and because ANY allegation of a
relationship between a vaccine and a serious adverse event are considered worth
investigating, the question of whether there is a
relationship – in this case between the MMR vaccine and autism – is often
studied by numerous researchers. In the case of MMR and autism -- other than a single
small study which had serious flaws in its methodology and has been questioned by most
other researchers -- no evidence of a link between the vaccine and autism has been found.
Yet the safety and the power of the vaccine, the tremendous number of lives it has saved
and disabilities that have been prevented by its use – that story was completely
absent from most coverage.
Unfortunately, prevention just doesn’t have the same news appeal. So,
we in the medical community clearly need to do a better job of communicating
both the benefits and the risks of vaccines and help all to better understand the diseases
they so effectively prevent.
There is a lot of information out there about vaccines, but not all of it
is scientifically correct and may feed into some of the parental misperceptions
we’re seeing. The Internet is one means by which both good and bad information is
spread. The Internet has had and will continue to have a tremendous influence on the
practice of and perceptions about medicine. Patients now come into doctors’
offices with printouts from the Internet to discuss. An Internet search on “vaccine
safety” will lead you to one of the top sites that states: “There is growing
evidence that immunization may cause a large number of chronic diseases including
diabetes, autoimmune diseases, allergies, asthma, cancers, and Gulf War Syndrome.”
Another “vaccine safety” site claims that the World Health Organization’s
neonatal tetanus immunization program is really a hidden birth control vaccine in
disguise.
Even if the scientific data does not support these conclusion these sites
usually contain powerful anecdotes from parents who believe their children
were harmed by a vaccine. That’s very believable to another parent. And these stories
get spread from parent to parent, neighbor to neighbor until the hypothesis becomes a fact
and people assume that they MUST be true. Just last week a television news program
in Boston featured Laurie Flutie, the wife of NFL quarterback Doug Flutie, and the parent
of an autistic son.
She said that she heard so much about the MMR vaccine that she eventually figured it had
to factor into her son’s disability.
If we in the medical and scientific community don’t speak out and do
everything we can to get the best information to all who want and need it, more and more
parents are going to continue to get the wrong messages.
How many times does history need to repeat itself?
We know that until a disease has been eradicated, a decline in
immunization rate provides fertile ground for an outbreak. We’ve seen it happen over
and over. In the 1970s and 1980s, large outbreaks of pertussis
returned to those countries that rejected the pertussis vaccine because of concern about
safety. The hypothesis that the MMR vaccine causes autism began in Britain. In the last
few years, acceptance of the MMR vaccine has dropped significantly there. In an even more
bizarre twist, some parents have become so fearful of the vaccine that they are hoping to
get their children invited to a “measles party” to intentionally expose them to
the disease first. I wonder whether they know that 1/1000 children who contract measles
suffer encephalitis, an inflammation of the brain, that can leave them permanently
disabled?
The spark has now found dry timber in Ireland. An outbreak of measles that
began in Dublin is now spreading around the countryside. At last report the case
counts were above 700, including at least two deaths among the many with complications
requiring hospitalization. Last year, the same thing happened in the Netherlands with over
3,000 cases of measles, and three deaths among the 500 who were hospitalized.
We don’t have to look to other countries to learn these same lessons.
A study in JAMA last year convincingly demonstrated that when measles returned to the
community, those who had opted out of immunization were
at a 35-fold increased risk of disease. While this example informs us of the magnitude of
the effectiveness of the vaccine, perhaps the more important feature of this study is the
finding that the outbreak that began among those who opted out of immunization spread into
the community at large – including those few who had been immunized but in whom the
vaccine didn’t “take.”
So while some parents say, "Look, there's not much disease in my
community, so my kid isn’t likely to get sick. Why should I risk a complication from
being vaccinated?” The answer is that the risks and consequences of getting these
diseases are far greater than the small risks associated with the immunizations. The
decision not to immunize one’s child is a decision that places that child and other
children in the community at greater risk.
There are many things we do to protect everyone in society that generally
require that we all play by the same rules. You can ignore the four-way stop sign as long
as others don’t. But if others have the same idea, that intersection may not be such
a safe place.
So, what can we do? We need to put in place a process that ensures that
the best information about immunization is available to all that need and want it.
The National Network for Immunization Information is taking the lead on
this with our work. We were created as a partnership among the Infectious Diseases Society
of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), the American Academy
of Pediatrics (AAP) and the American Nurses Association (ANA). We are channeling the
expertise of these organizations into developing educational tools for doctors, nurses,
and other healthcare clinicians. We have created a “resource kit” to help
providers communicate with their patients on vaccine-related issues, which
we’re going to distribute and make available on our web site later this year.
We are also creating a web site that will contain the latest scientific
information on vaccine-related issues, for parents as well as for providers and
policymakers – everyone who makes decisions about vaccination. Like medicine itself,
our decisions about immunization should be based on the best available evidence, not
anecdote and innuendo.
We believe that there is a pressing need to correct the misperceptions and
help parents, policymakers and the media better understand why the experts and their
doctors recommend that all children be fully protected through immunizations.
Unless we make a concerted effort to provide the best information that we
can, these misperceptions are likely to grow rather than diminish in the future. Our goal
is to keep the iron lungs in the museums and the images of these diseases locked in black
and white photos.
REFERENCES
CDC. Achievements in Public Health, 1900-1999 Impact of Vaccines
Universally Recommended for Children -- United States, 1990-1998. MMWR April 2, 1999,
48(12);243-248
Chen RT, Hibbs B. Vaccine safety: current and future challenges. Pediatr
Ann. 1998 Jul;27(7):445-55
Gangarosa EJ, Galazka AM, Wolfe CR, Phillips LM, Gangarosa RE, Miller E,
Chen RT. Impact of anti-vaccine movements on pertussis control: the untold story.
Lancet. 1998 Jan 31;351(9099):356-61.
Gillberg C and Heijbel H. MMR and autism. Autism 1998;2:423-4.
Measles, MMR, and autism: the confusion continues [Editorial]. Lancet
2000; 355: 1379.
Peltola H, et al. No evidence for measles, mumps, and rubella
vaccine-associated inflammatory bowel disease or autism in a 14-year prospective study.
Lancet. 1998; 351(9112):1327-8.
Rodier PM. The early origins of autism. Sci Am. 2000 Feb;282(2):56-63.
Salmon DA, Haber M, Gangarosa EJ, Phillips L, Smith NJ, Chen RT. Health
consequences of religious and philosophical exemptions from immunization laws: individual
and societal risk of measles. JAMA. 1999 Jul 7;282(1):47-53.
Taylor B, et al. Autism and measles, mumps and rubella vaccine: No
epidemiological evidence for a causal association. Lancet. 1999; 353 (9169):2026-9.
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