Vaccination Wars and Why They Matter

Wed, 10 Oct. 2012 - 2:15 a.m. MT
Credit: ARA Staff - American Running Association

A newly published Associated Press analysis reveals that the disputes between health officials and parents who opt out of immunizing their children are far from resolved in the U.S.—and in a wider context, the rising vaccination exemption rates found in over half of the states now threaten to become a nationwide public health issue. It’s worth considering the factors that have led to a growing, not shrinking, suspicion of childhood immunization programs, and attempting to summarize just what’s at stake and why.

The AP asked state health departments to submit kindergarten exemption rates for school years 2006-07 and 2010-11, and they also looked at previously gathered federal data. In eight states, more than one in 20 public school children do not get the vaccines that are required for kindergarten attendance. For context, health officials worry when some states have exemption rates climbing beyond 5 percent; Last year, Alaska’s exemption rate was nearly 9 percent. Colorado's rate was 7 percent, and Vermont and Washington State were at 6 percent. Michigan, Illinois, and Oregon were also among the top states.

These diseases still exist

As the Centers for Disease Control and Prevention point out, in the U.S. vaccination programs have eliminated or significantly reduced many vaccine-preventable diseases, but many of them—in particular, whooping cough, chickenpox, meningitis-causing Hib, measles, hepatitis B, and of course influenza—are still circulating nationwide and can once again become common and even deadly if vaccination does not continue at high levels. And elsewhere in the world, still other diseases flourish. What’s worse, there is usually no way to know in advance whether a child will contract a mild or serious case of a given disease. Only vaccination effectively pre-empts this troubling reality.

Why don’t parents vaccinate?

The medical community has struggled for years to reassure parents that childhood vaccinations are safe, but the number of parents who skip the shots disconcertingly grows. There are also pockets in some states where opt-out rates are much higher than the statewide average. In some rural counties in northeast Washington, for example, exemption rates in recent years have been above 20 percent and even as high as 50 percent.

There are a variety of reasons some parents are skeptical of immunization programs. It’s difficult to ignore the influence of Andrew Wakefield, who in 1998 published a paper about a link between the measles/mumps/rubella (MMR) vaccine and autism. The study was unequivocally debunked several years ago and has been repeatedly condemned by the scientific community. In 2010, the British Medical Journal even took the unusual step of retracting the 1998 paper, citing falsification of data in the study and calling its conclusions "fraudulent."  But, as easy as it was to frighten parents initially, it seems equally difficult to unscare them. 


To be sure, childhood vaccination rates remain high overall, at 90 percent or better for several vaccines, including those for polio, measles, hepatitis B, and chickenpox. Yet while it’s widely understood among pediatricians and other medical professionals that immunizations are on par with penicillin as a breakthrough achievement in the history of medicine, the CDC says that nationally more than 75 percent of parents have at least one question or concern about their child's vaccines. Some parents are skeptical that vaccines are essential. Others fear vaccines carry their own risks. But the fact remains that very few serious problems have turned up over decades of immunizing the public.

Vaccines are very safe, with the overwhelming majority of adverse events being minor and temporary, such as a sore arm or mild fever. So few deaths can plausibly be attributed to vaccines that it’s hard to assess that risk statistically at all. The CDC reports, for instance, that of all deaths reported to the Vaccine Adverse Event Reporting System between 1990 and 1992, only one is believed to be even possibly associated with a vaccine. The Institute of Medicine in its 1994 report states that the risk of death from vaccines is "extraordinarily low."

Assessing the real risk

Without vaccines, there would be many more cases of disease, and with them many more deaths. Comparing the risk from disease with the risk from vaccines can give us an idea of the benefits we get from vaccinating our children:

DTaP Vaccine Data

 

Disease

Deaths

Other Complications

Diphtheria

1 in 20

-

Tetanus

2 in 20

-

Pertussis

1 in 1,500

pneumonia, 

1 in 8

 

 

encephalitis, 

1 in 20

Vaccine

Deaths

Other Complications

DTaP

none proven

continuous crying, then full recovery,

1 in 1,000

 

 

convulsions or shock, then full recovery,

1 in 14,000

 

 

acute encephalopathy,

0-10.5 in 

1 million

 

Source: Centers for Disease Control and Prevention

MMR Vaccine Data

 

Disease

Deaths

Other Complications

Measles

2 in 1,000

pneumonia,

6 in 100

 

 

encephalitis,

1 in 1,000

Rubella

-

congenital rubella syndrome,

1 in 4 if infected early in pregnancy

Vaccine

Deaths

Other Complications

MMR

-

encephalitis or severe allergic reaction,

1 in 1 million 

 

Source: Centers for Disease Control and Prevention

From this data we can see that a child is far more likely to be seriously injured by one of these diseases than by any vaccine. While any serious injury or death caused by vaccines is too many, it is also clear that the benefits of vaccination greatly outweigh the slight risk, and that many, many more injuries and deaths would occur without vaccinations. In fact, as the CDC eloquently puts it on their very informative website (see cites below), “To have a medical intervention as effective as vaccination in preventing disease and not use it would be unconscionable.”

Herd immunity and the importance of group compliance

There is a major reason public awareness needs to be raised about the safety and necessity of immunizing all children: Even if you have vaccinated your own child, your child's risk of getting a disease depends greatly on what your neighbors do. In any epidemic, some portion of the vaccinated populous always contracts the disease regardless. Historically, when smallpox was killing 30 percent of its victims or more, the odds clearly favored vaccination. In a mild epidemic, where few people died, rejection of the vaccine made far more sense. 

But, as Michael Specter points out in an in-depth analysis of vaccination in The New Yorker from May, 2011, “The social calculus of vaccination can never be reduced to the estimation of individual benefit. When most members of a community are vaccinated, they protect those who are not by eliminating the viral reservoirs in the population. The effect is known as herd immunity. Some people, because they are too young or have particularly weak immune systems owing to cancer or other illnesses, cannot be vaccinated. For them, herd immunity is the only defense. As long as the majority are vaccinated, then, a few can decline without courting harm, but when vaccination rates fall below a certain level this protection quickly begins to vanish. At that point, someone who refuses a vaccine imperils not only his own health but that of everyone he encounters.” 

Specter notes that what makes it easy to be a vaccine dissenter these days is the fact that most people aren’t. Because of routine vaccination, measles—which kills at least 150,000 people in the developing world each year—long ago ceased to be a significant threat in the U.S. 

In fact, measles is one of the most contagious diseases known, and just one case in a community is cause for serious concern. Hours after an infected person has left a room, an unvaccinated person can acquire measles just by entering the room. Studies of the American population have found that communities with higher exemption rates have sometimes seen measles re-emerge in outbreaks. In May, for example, there was a measles outbreak in Minnesota. (The state originally ranked in the top eight for 2010-11 kindergarten immunization exemptions, but since has disputed the AP’s data.) 

Uncontested outbreak data

Immunization success creates a paradox. Public health officials must struggle constantly with the consequences of their own success: the dangers of complacency are real. Vaccine-preventable illnesses have made a strong resurgence in the past decade in the U.S., fueled almost wholly by fear. More than 600 cases of whooping cough were reported in Washington last year, double the previous year. Last year, California had more than 2,100 whooping cough cases, and 10 infants died. 

We can look at the experiences of several developed countries after they let their immunization levels drop. Three countries—Great Britain, Sweden, and Japan—cut back the use of the pertussis vaccine because of fears about it. The effect was dramatic and immediate. In Great Britain, a drop in pertussis vaccination in 1974 was followed by an epidemic of more than 100,000 cases of pertussis and 36 deaths by 1978. In Japan around the same time, a drop in vaccination rates from 70 percent to between 20 and 40 percent led to a jump in pertussis from 393 cases (and no deaths) in 1974 to 13,000 cases (and 41 deaths) in 1979. In Sweden, the annual incidence rate of pertussis per 100,000 children 0 to 6 years of age increased from 700 cases in 1981 to 3,200 in 1985. It seems clear that we not only count upon vaccines to eradicate these diseases, but should vaccinations languish, we can equally count upon these diseases coming back.

Indeed, China was polio free for two decades, but this year they were infected from Pakistan, and now there is a large polio outbreak there. In the U.S., outbreaks of Hib occur periodically among the Amish, who don't consistently vaccinate their children. And in the 90s in Russia, as vaccinations declined, an otherwise preventable outbreak of diphtheria erupted. Wherever a population forgoes immunizations, there is no reason to think other vaccine-preventable diseases would behave differently, including hepatitis B, pneumococcal, rubella, tetanus, and mumps.

Tertiary concerns

Finally, when a vaccine-preventable disease occurs in a community, unvaccinated children are ordinary removed from school, childcare, and extracurricular sports, sometimes for several weeks. This impacts the child in less troublesome ways but in ones that are entirely preventable by making sure s/he is immunized. And since parents are required to tell medical staff when their child has not received all the recommended vaccines for his/her age, ethical dilemmas may arise for pediatricians, who sometimes decide to “fire” patients who aren’t vaccinated.

The reason is that, if a pediatrician continues to care for an unvaccinated patient, there is a tacit acceptance of this decision by the parents. Because some diseases are genuinely disabling, if the child does come down with one of these, it can make the doctor feel complicit and partly to blame.

Let us remember that before smallpox was eradicated in 1977, it killed 300 million people in the 20th century alone. Without continued, systematic immunization of the world’s population, there is simply no reason to think that pandemics are strictly a thing of the past. 

Boston Globe, “AP IMPACT: More Kids Skip School Shots in 8 States,” by Mike Stobbe, Nov. 28, 2011, http://www.boston.com/news/education/k_12/articles/2011/11/28/ap_impact_more_kids_skip_school_shots_in_8_states_1322490562/?page=full


CDC vaccination information for doctors, caregivers, and parents, 2011, www.cdc.gov/vaccines/parents

http://www.cdc.gov/vaccines/spec-grps/hcp/conv-materials.htm

http://www.cdc.gov/vaccines/vac-gen/6mishome.htm

 

OregonLive.com, “Washington State Leads Nation in Parents Opting out of Vaccinations for Their Children,” July 31, 2011, http://www.oregonlive.com/pacific-northwest-news/index.ssf/2011/07/washington_state_leads_nation_in_opting_out_of_childhood_vaccinations.html

 

The New Yorker, “Resistant: Why a Century-old Battle Over Vaccination Continues to Rage,” by Michael Specter, May 30, 2011, http://www.newyorker.com/arts/critics/books/2011/05/30/110530crbo_books_specter?currentPage=1

 

(RUNNING & FITNEWS® November / December 2011 • Volume 29, Number 6)





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