Spreading the message of vaccine safety

“It is the imperative duty of the physician to see to it that every young infant is vaccinated, and no foolish sentiment or prejudice on the part of the parents should be allowed to stand in the way.” – L. Emmett Holt, MD, 1897, The Diseases of Infancy and Childhood

More than 100 years ago, these words from one of the founders of American pediatrics echo emotions still in play today.

I am very happy to see that the recently released committee report of the Institute of Medicine (IOM) strongly reinforced the safety of vaccines, finding few adverse effects related to eight vaccines — varicella zoster, influenza (except 2009 H1N1), hepatitis B, human papillomavirus, measles-mumps-rubella (MMR), hepatitis A, meningococcal and those that contain tetanus.

The report found data to convincingly support a causal relationship of the varicella zoster vaccination, a live vaccine, with specific adverse events all due to infection from the vaccine strain; the MMR vaccine with febrile seizures (almost always benign), as well as a separate association with a rare encephalitis; and with many of the vaccines an association with anaphylaxis was reported.

A convincing relationship between injection of vaccine, independent of antigen, and syncope and deltoid bursitis was also found. The evidence also favors acceptance of a relationship of the MMR vaccine and transient arthralgias. None of these conclusions should surprise any pediatrician, nor should they be difficult to review with families.

Most importantly, the reviewed evidence favors the rejection of five vaccine adverse event relationships: MMR vaccine and autism; MMR vaccine and type 1 diabetes; diphtheria and tetanus toxoids and acellular pertussis vaccine, and type 1 diabetes; inactivated influenza vaccine and Bell’s palsy; and inactivated influenza vaccine and exacerbation of asthma.

Evidence-based good news

Coming in sequence with similar conclusions by other scientific bodies, one would think that there would be cries of relief from the pediatric primary care community. Undoubtedly, there are some rejoicing general pediatricians, but I suspect their celebration, like mine, is rather muted. In reading the popular press reviews of the report, I was struck by the equal weight being given to the opinions rejecting these findings by those communities strongly opposed to vaccination, including many so-called public interest groups (really single-issue, self-interest advocacy groups — including several self-promoting pediatricians) and chiropractic practitioners.

I try not to discuss religion or politics, but it is hard not to comment on the media and its current state of practice to give equal weight in reporting to fringe groups and ideas, particularly when evidence is overwhelmingly against their professed views. The danger of giving equal standing to such groups is substantial and not to be ignored. This debate is framed in the popular media, expanded on the Internet, then placed on our plates in the office. An anti-science, anti-government bias is currently strongly represented in our public discourse and it frustrates better practice. Despite its independent status, the IOM is not immune to indiscriminant dismissal.

Vaccine refusal

Vaccine refusal is a difficult situation to manage in practice. The ethical and moral imperatives are complicated. The risks to the individual child of not being vaccinated are real and well documented, as are the risks to others in the community who, by their own immune status, age, or by insufficient numbers of others in the community being vaccinated, are made vulnerable to vaccine-preventable disease. Many of us in practice will attempt to convince fearful parents and allow some time to pass as the issues of vaccine risks and benefits are discussed in multiple office visits. However, given that the recommended vaccine schedule requires more than 25 vaccines in the first 2 years of life, delaying vaccines not only increases disease risk, but complicates compliance and, ultimately, efficacy. Because of these concerns, an increasing number of practices are refusing to care for families who refuse vaccination.

The very effectiveness of vaccines works against their provision. Parents who refuse vaccination underestimate the infection risks, in part because of the infrequency of disease caused by the success of vaccination. Ethical guidelines are careful to weigh both the obligation to provide ongoing care without limiting access and the true risk for infection to the individual patient. Harder to quantify in any individual case is the community risk, which will increase if overall vaccine use declines. It is clear that, at any moment, infants in our waiting rooms are at risk for pertussis and measles, and frequently, patients who are immunocompromised by medication and/or malignancy are also at risk for those and other vaccine-preventable illness.

Communities at risk

Those parents who refuse immunizations on nonmedical grounds are generally well-educated, but are either wrong in their interpretation of risk or willfully choosing to put their children and communities at risk by their actions. For those practitioners in states where nonmedical exemptions to vaccination are allowed, perhaps advocating for more directed counseling before such elections are allowed would persuade some to vaccinate. Or, more dramatically, pursuing mandated vaccination legislation as both a legal and appropriate ethical direction may be necessary, as we have begun to see resurgence in some vaccine-preventable diseases, most notably measles. Of course, pursuing such a course, even if ethically appropriate, would likely generate even increased opposition and might risk even less compliance.

Most parents who refuse vaccines worry about potential harm associated with vaccines. The data overwhelmingly support safety and efficacy. Little argument can be made that the most effective preventive medical intervention available to us in the office setting is vaccination.

There is hope, if the message of safety can get out to truly improve the health of our patients and our communities.

Institute of Medicine of the National Academies. Adverse effects of vaccines: evidence and causality. Aug. 25, 2011. Available at: www.iom.edu/Reports/2011/Adverse-Effects-of-Vaccines-Evidence-and-Causality.aspx

William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Gerson reports no relevant financial disclosures.

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