Sometimes, even on SBM, we need to lighten things up a bit. Take that, Mike Adams!
Archive for Vaccines
The Supreme Court of the United States made a ruling the other day that has profound implications for the health of millions of children. Since October 12, 2010, The Court has been quietly deliberating the case of Bruesewitz v. Wyeth, inc. The case centers on Russell and Robalee Bruesewitz’s allegation that their 18 year old daughter, Hannah, was irreversibly injured by a DTP vaccine she received when she was 6 months old. What is important about this case is not the allegation itself (I will discuss its merits, or lack thereof, in a moment), but the ramifications the ruling has for the future of childhood immunization in this country. The Supreme Court’s ruling against the Bruesewitz’s and in favor of the U.S. vaccination program was the right one, and safeguards our children from the irrationality of the anti-vaccine movement. Some important background is necessary here to understand why this is so.
Prior to the development of effective vaccines, diphtheria, tetanus, and pertussis were common diseases, terrifyingly familiar to all parents. Death records from Massachusetts during the latter half of the 1800’s indicate that diphtheria caused 3-10% of all deaths. In the first part of the 20th century, these dreaded organisms still caused illness in hundreds of thousands of people each year in the United States. These are devastating diseases which, if not resulting in death, often produced severe and permanent damage to those afflicted. In the 1920’s, vaccines against each of these scourges were finally developed, and in the mid 1940’s the combined DTP vaccine was introduced. The vaccines were so effective that cases of these deadly infections were practically eliminated. Today, few parents know the terror once routinely wrought by these pathogens.
The Australian anti-Vaccination Network (AVN) in Australia has not been having a good time of late.
First, they were smacked down by the Health Care Complaints Commission. Following a 12 month investigation into the information provided on the AVN’s website, the HCCC issued a public warning stating the AVN “pose(s) a risk to public health and safety”.
The AVN was then investigated by the charity watchdog in New South Wales, the OLGR (yes you are not alone in thinking “why the hell are they a charity?”) which found that the AVN had “…breached charitable fundraising laws and potentially misled the public”. This was largely as a result of their collecting funds for one purpose and then spending the money elsewhere - something you’re not allowed to do as a charity.
For example, in 2008 the AVN collected $11,810 for a “Fighting Fund”, an appeal set-up to raise money to support a family allegedly on the run from a court order to immunize a child. But the OLGR reported none of the funds raised were spent on this cause.
Last year it was reported that there was a possible increase in narcolepsy, a sleep disorder characterized by excessive sleepiness, in children who had received the Pandemrix brand of H1N1 flu vaccine in Sweden, Finland, and Iceland. However a review of the data did not find a convincing connection, although concluded there was insufficient data at present and recommended further surveillance. A narcolepsy task force was formed in Finland, and now we have their preliminary report.
They conclude that the evidence suggests there is a connection:
Based on the preliminary analyses, the risk of falling ill with narcolepsy among those vaccinated in the 4-19 years age group was 9-fold in comparison to those unvaccinated in the same age group. This increase was most pronounced among those 5–15 years of age. No cases were observed among those under 4 years of age. Also, no increase in cases of narcolepsy or signs of vaccination impacting risk of falling ill with narcolepsy was observed among those above 19 years of age.
The World Health Organization (WHO) has reviewed these results and concluded:
WHO’s Global Advisory Committee on Vaccine Safety (GACVS) reviewed this data by telephone conference on 4 February 2011. GACVS agrees that further investigation is warranted concerning narcolepsy and vaccination against influenza (H1N1) 2009 with Pandemrix and other pandemic H1N1 vaccines. An increased risk of narcolepsy has not been observed in association with the use of any vaccines whether against influenza or other diseases in the past. Even at this stage, it does not appear that narcolepsy following vaccination against pandemic influenza is a general worldwide phenomenon and this complicates interpretation of the findings in Finland.
|The Colbert Report||Mon – Thurs 11:30pm / 10:30c|
Looks like a win to me. I particularly like how Dr. Offit says that the question of whether vaccines cause autism has been “asked and, fortunately, answered.” Heh. That’s a shot across the bow to J.B. Handley, who, as Steve Novella has pointed out (as have I) is utterly clueless about science and how to interpret the medical literature, as he has demonstrated time and time again with his “14 Studies” nonsense. Of course, anyone who calls Handley out on his ignorance is subject to personal attack. Reporters have felt it. Steve Novella has felt his wrath. So have I. Meanwhile Handley gloats over the decline in confidence in vaccines that his organization Generation Rescue has helped foster.
Fortunately, Colbert appears to get it. I like how Colbert does a faux rejection of one of Dr. Offit’s points by pointing out that he is “ruled by fear.” I particularly like how he mentions Andrew Wakefield, but not by name (rather like Lord Voldemort), and how he asks Dr. Offit a bunch of questions based on talking points the anti-vaccine movement likes to use to frighten parents. No wonder the anti-vaccine collective at Age of Autism is going crazy, having posted (and reposted) numerous attacks old and new on Paul Offit ever since it was announced that he was going to be on The Colbert Report last night, all topped off with one by J.B. Handley himself in which he calls Dr. Offit a “blowhard liar.”
Stay classy, J.B. Stay classy.
Last week, the British Medical Journal (BMJ) published an expose by investigative journalist Brian Deer that enumerated in detail the specifics of how a British gastroenterologist turned hero of the anti-vaccine movement had committed scientific fraud by falsifying key aspects of case reports that he used as the basis of his now infamous 1998 Lancet article suggesting a link between the MMR vaccine and a syndrome consisting of regressive autism and enterocolitis. Indeed, Deer even went so far as to describe Wakefield’s fraud as “Piltdown medicine,” comparing it explicitly to the infamous “Piltdown man” hoax, and in an accompanying editorial the editors of the BMJ agreed. These revelations were not by any means new. Scientists had suspected that something wasn’t quite right about Wakefield’s work almost as soon as it had been published, and by 2004 Brian Deer had uncovered clear evidence of major undisclosed conflicts of interest on Wakefield’s part. Unfortunately, by that time the proverbial cat was out of the proverbial bag, and Wakefield’s fraudulent research, aided and abetted by his flair for self-promotion in the media and some truly execrable, credulous, and sensationalistic coverage by the British press, had ignited a major scare over the MMR vaccine. MMR uptake rates plummeted below levels necessary for herd immunity, and measles came roaring back with a vengeance in the U.K. By the time the British General Medical Council finally ruled about a year ago that Wakefield had committed research fraud and violated research ethics in the work reported in his 1998 Lancet article and recommended that he be “struck off” (i.e., have his license to practice medicine in the U.K. revoked), the damage had been done.
As important as Wakefield is to the genesis of the modern anti-vaccine movement, however, there is another force that acts far more “where the rubber hits the road,” so to speak. This force comes in the form of publications and online discussion forums that cater to new mothers, offering all manner of advice and support. Some of these are very good, but all too many of them are hotbeds of anti-vaccine pseudoscience, confidently proclaimed by “elder statesman” members of these forums and included in articles published in glossy, attractive magazines. As a rather ironic coincidence, just as news of Andrew Wakefield’s latest humiliation was finding its way out into multiple news outlets last week, the first issue of 2011 of just such a glossy publication hit the shelves. I’m referring to Mothering, whose tagline is “Inspiring Natural Families Since 1976.” In reality, it should read: “Inspiring quackery and anti-vaccine views since 1976.” Of course, in the world of “alt-med,” the two often go hand-in-hand. In any case, one of our readers sent me a link to the latest issue of Mothering. Unfortunately, I can’t supply you with that link, because it’s for subscribers. I will, however, describe and quote articles and passages that demonstrate just what a wretched hive of scum and quackery Mothering is, particularly with respect to vaccines but not limited to vaccines. Taking into account its large and vigorous online forums, Mothering is major force for the promotion of anti-vaccine views and quackery among new mothers.
Pity poor Andrew Wakefield. Well, not really. I tend to view what’s happening to him yet again as the chickens coming home to roost.
Let’s put it this way. 2010 was a terrible year for him, and 2011 is starting out almost as bad. In February 2010, the General Medical Council in the U.K. recommended that Wakefield be stripped of his license to practice medicine in the U.K. because of scientific misconduct related to his infamous 1998 case series published in The Lancet, even going so far as to refer to him as irresponsible and dishonest, and in May 2010 he was. This case series, thanks to Wakefield’s scientific incompetence and fraud, coupled with his flair for self-promotion and enabled by the sensationalistic credulity of the British press, ignited a scare about the measles-mumps-rubella (MMR) vaccine in which, afraid that the MMR vaccine causes autism, parents in the U.K. eschewed vaccinating their children in droves. As a result, vaccination rates plummeted far below the level necessary for herd immunity, with the entirely predictable result of massive measles outbreaks in the U.K. Measles, which as of the mid-1990s had been declared under control by British and European health authorities, came roaring back to the point where in 2008 it was declared once again endemic in the British Isles. In a mere decade and a half, several decades of progress in controlling this scourge had been unravelled like a thread hanging off a cheap dress, all thanks to Andrew Wakefield and scandal mongers in the British press.
True, Wakefield had long since moved to Texas, the better to be the founding “scientific director” of a house of autism woo known as Thoughtful House. Thus, the removal of his license to practice had little practical import (or effect on his ability to earn a living), or so it seemed at the time, given that Wakefield did not treat patients and hauled in quite the hefty salary for his promotion of anti-vaccine pseudoscience. Fortunately, karma’s a bitch, and, as a result of the GMC’s action, in short order The Lancet retracted Wakefield’s 1998 paper; Wakefield was pushed out of Thoughtful House; and his latest attempt to “prove” that vaccines cause autism in an animal study was also retracted. Investigative reporter Brian Deer’s investigation finding that Andrew Wakefield had committed scientific fraud in carrying out his Lancet study joined prior findings that Wakefield had been in the pocket of trial lawyers (to the tune of £435 643, plus expenses) seeking to sue the vaccine industry at the time he carried out his “research” and the allegations by renowned PCR expert Stephen Bustin during the Autism Omnibus as to how shoddily Wakefield’s other research was carried out. Finally, the mainstream media started to back away from its previous embrace of Wakefield and his claims. As a result, for a while at least, Wakefield was reduced to lame appearances at sparsely attended anti-vaccine rallies last spring.
The year 2011 is starting out rather promisingly, at least from the point of view of science-based medicine. Its beginning coincides with the release of two — count ‘em, two! — books taking a skeptical, science-based look at vaccines and, in particular, the anti-vaccine movement. First off the mark is a new book by a man whom the anti-vaccine movement views as the Dark Lord of Vaccination, sitting up in Barad-dûr (apparently the University of Pennsylvania and Children’s Hospital of Philadelphia), a man utterly reviled by anti-vaccine quacks everywhere, Dr. Paul Offit. He has been subjected to considerable bile and harassment due to his simply standing up for the science behind vaccines. The book is entitled, appropriately enough, Deadly Choices: How the Anti-vaccine Movement Threatens Us All. Also being released is a new book by Seth Mnookin entitled The Panic Virus: A True Story of Medicine, Science, and Fear. Mnookin is a contributing editor at Vanity Fair and whose work has appeared in numerous publications. Because I got a copy of Deadly Choices before my copy of The Panic Virus arrived, I decided to review Deadly Choices first; after I’ve managed to read The Panic Virus, I’ll write a review of it as well. Both books are arrows shot at the heart of the pseudoscience and fear at the heart of the vaccine manufactroversy, and it might well be useful to compare and contrast the two once I’ve finished The Panic Virus.
In the meantime, let’s take a look at Deadly Choices, an excellent, well-researched book with which I have relatively few disagreements. It is a followup to Dr. Offit’s last book, Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure, which I reviewed back when it first came out. In contrast to Autism’s False Prophets, which concentrated primarily on the manufactroversy that claims that vaccines are responsible for the “autism epidemic,” Deadly Choices steps back to take a broader look at the anti-vaccine movement. Regular readers of SBM hardly need to be reminded how pervasive and dangerous the modern-day anti-vaccine movement has become. Indeed, it is a frequently discussed theme of this blog, given that the anti-vaccine movement is such a major force among the forces that deny the efficacy of scientific medicine and seek either to replace it with unscientific or pseudoscientific “alternatives” or to “integrate” pseudoscience into science-based medicine. Indeed, anti-vaccine sentiment infuses large swaths of what we refer to as “complementary and alternative medicine” (CAM), be it chiropractic, homeopathy, traditional Chinese medicine, or a wide variety of other modalities and systems.
In examining the modern anti-vaccine movement, Dr. Offit structures his book into three major sections. First, beginning in a chapter entitled The Birth of Fear, Dr. Offit begins with a description of the birth of the modern anti-vaccine movement, which in the U.S. Dr. Offit traces, in large part, to the broadcast of an irresponsible and anecdote-driven news documentary about the diptheria-pertussis-tetanus (DPT) vaccine in 1982, and in the U.K. to a scare about the DPT triggered by a presentation by Dr. John Wilson to the Royal Society of Medicine about horrific complications thought to be due to the pertussis vaccine in the DPT. Next, Dr. Offit goes back into history to describe the development of the anti-vaccine movement in the 1800s in England and notes parallels with the modern day anti-vaccine movement. Finally, the story shifts back to today, where he describes the situation now, how demands for vaccines turned into fear of vaccines, and what we might do about it.
As much as I support vaccines, I see the short term consequences. Vaccines can be painful. Kids don’t like them, and parents don’t like seeing their children suffer. That this transient pain is the most common consequence of gaining protection from fatal illnesses seems like a fair trade-off to me. But that’s not the case for every parent.
Today’s post isn’t going to focus on the extremes of the anti-vaccination movement. Rather, it’s going to look at ways to make vaccines less painful and more acceptable to children. The pain of vaccines can lead to anxiety, fear, and even nonadherence with vaccination schedules. Fear of needles and injections is not uncommon, it’s estimated that 10% of the population avoids vaccinations for this reason.
The vaccine schedules are intense. Where I live, the public vaccination schedule specifies seventeen injections of six different products over six visits in the first 18 months of life, plus influenza vaccinations and one-offs like H1N1. That’s a lot of visits, and a lot of tears if a child doesn’t handle them well.
In light of what’s known about the prevalence of needle fears, their potential effect on vaccination adherence (that could persist through adult life), and the possible impact on public health because of unvaccinated individuals, it makes sense to do whatever we can to minimize the pain and discomfort of vaccines, increasing their acceptance to children and their parents. But what works? I’ve personally found Smarties (the real ones) and Dora the Explorer stickers are effective distractions and bribes. But I’m not about to call my n=2 trial good science. Nicely, there’s much more evidence to guide our recommendations.
I have a love-hate relationship with epidemiology.
On the one hand, I love how epidemiology can look for correlations in huge sample sizes, sample sizes far larger than any that we could ever have access to in clinical trials, randomized or other. I love the ability of epidemiology to generate hypotheses that can be tested in the laboratory and then later in clinical trials. Also, let’s not forget that epidemiology is sometimes the only tool available to us that can answer some questions. Such questions generally involve hypotheses that can’t be tested in a randomized clinical trial because of either ethical concerns or others. A good example of this is the question of whether vaccines cause autism. For obvious ethical reasons, it’s not permissible to perform a randomized clinical trial in which one group of children is vaccinated and one is not, and then outcomes with respect to neurodevelopmental outcomes, such as autism and autism spectrum disorders, are tracked in the two groups. The ethical concern with such a study, of course, is the potential harm that would be likely to come to the unvaccinated control group, children who would be left unprotected against common and postentially deadly communicable diaseases.
On the other hand, epidemiology is one of the messiest of sciences, and epidemiological studies are among the most difficult in all of science to perform truly rigorously. The number of factors that can confound are truly amazing, and as a result, it’s very, very easy for an epidemiological study to detect apparent correlations that are either spurious or appear much stronger than the “true” correlation. There can be confounding factors beneath confounding factors wrapped in more confounding factors, the relationships among which are not always apparent. Not infrequently, a condition can appear to be correlated with, for instance, an environmental factor, but in reality that environmental factor and the condition both correlate with a third, unknown confounder. Worse, epidemiologists know that correlation does not necessarily equal causation, but the general public, for the most part, does not, which is why, when anti-vaccine activists, for instance, point out to a rising autism prevalence and then point out that autism prevalence started rising around the same time the vaccine schedule was expanded, to the average layperson the argument sounds compelling. As a result, the design of an epidemiological study is paramount in order to account for or minimize such factors. That’s why I always said I can’t be an epidemiologist. Even though I was very good at math in college, the statistics still made my brain hurt, and I don’t have the patience for the messiness of trying to account for all the possible confounding factors.
However, for all their strengths and flaws, epidemiological studies are an integral part of science-based medicine. They are used to identify predisposing factors to diseases and conditions, environmental contributors to disease, and adverse reactions to drugs, among many other useful pieces of data. That’s why, from time to time, I like to examine epidemiological studies, particularly if they’re epidemiological studies that are getting a lot of press.
The use and abuse of autism epidemiology studies
For instance, studies like this one described in a story in the Los Angeles Times on Friday entitled Proximity to freeways increases autism risk, study finds: More research is needed, but the report suggests air pollution could be a factor: