When vaccines cause all of the problems and none of the solutions

My involvement in the effects of vaccination on the microbiome discussion seems to be wrapping up as most of the anti-vaxers involved have admitted that they either don’t understand science, don’t care about it or are disillusioned by it. Amusingly, these are the same people who offered plenty of criticism about the lack of science cited when I wrote about my personal experience as an anti-vax mom. Yet, when we’re actually discussing a specifically scientific issue, they want to lean back into their personal experiences. Whatever.

Ultimately what has happened in that discussion is that the anti-vaxers want to give all the credit for reduction in disease to anything other than vaccination, while at the same time blaming individual vaccines for nearly everything that has emerged in public health since the introduction of the vaccine. I’m exaggerating the case here, but that’s pretty much what’s going on. There was much resistance to the well-studied observation that disease from S. pneumoniae dramatically declined following the first Prevnar vaccine. But absolute insistence that Prevnar is directly responsible for the increase in MRSA based on scant evidence that the vaccine has any effect on MRSA. It was all followed up with a dire prediction that “the current system is going to end up killing a whole lot of people and someone will be able to overcome the noise and connect it to the vaccine. ”

The vaccine either reduces carriage of the microorganism S. pneumoniae or it doesn’t. If it does, then we can start to hypothesize about the consequences of that. Giving the vaccine all of the credit for the bad stuff (even future calamities) but no credit for the marked reduction in Strep related diseases is wildly illogical. The vaccines appear to have only a modest impact on carriage of microbe species overall, or may have no significant impact on carriage, as suggested by this study that will be published in January 2015.

If they don’t affect carriage of Sp then all of the hypotheses that hinge on that– like the idea that increased rates of MRSA is due to Prevnar– go sailing out the window. You can no longer blame Prevnar for the prophesied future microbial takeover.

The picture is incomplete because the microbiome is an emerging field of study. That is often the case with science, and we don’t just abandon efforts to improve our situation until we’ve answered every question. Sometimes we may not know which questions to ask until we’ve actually made some attempts to affect a change. This isn’t only science, but life.

In conclusion (on my part) the results of hundreds of studies have given no cause for alarm despite some concerns about serotype replacement popularized by the media over the past 7 years or so. The disagreements between myself and my anti-vax counterparts seem to be based primarily on who is willing to make predictions of calamity based on incomplete knowledge. In the medical world there’s an approach called “watchful waiting” or “expectant management.” While “watchful waiting” has been shown to have outcomes just as good or better when it comes to some health conditions, it’s use is only medically justified in certain circumstances. Preventing infectious disease isn’t one of those circumstances.

It seems like the very cautious anti-vaxers also want this approach to apply to vaccines. The flawed assumption is that in the absence of a crystal clear understanding, it will always be safer to do nothing. When it comes to prevention of infectious diseases, watchful waiting doesn’t get us anywhere. The recommended vaccine schedule has been determined to be superior to any type of watchful waiting for everyone except those with known, diagnosed medical contraindications.

In the absence of preventive vaccination programs, contagious diseases will be much more common. The “watchful waiting” alternative in this situation means waiting for an outbreak or an epidemic to spur some people to either rush to vaccine clinics or seek medical care for the disease they catch. That’s simply not the best approach.

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Is “anti-vaccine” a pejorative?

Anti-vaxers hate being called anti-vaccine. Apparently, even categorizing vicious vaccine-opponents as a group, e.g. the “anti-vaccine movement” is insulting.

The term "anti-vaccine" is a pejorative

Wow.

From “Sara’s” first sentence (“When I was expecting my first child, I was introduced to the anti-vaccine movement,”) the tone is insulting at best. The term “anti-vaccine movement” is a pejorative; it’s meant to polarize and denigrate people who question or criticize vaccine safety. If you criticize Toyota for the fact they they didn’t admit problems with stuck accelerator, and even tried to cover up the issue, that doesn’t make you anti-car. Calling critics “anti-vaccine” is a deliberate attempt to demean and polarize.

Far more troublesome is the number of generalizations that gloss over or even ignore facts that refute her position.

I don’t care.

I don’t care that these people’s feelings get hurt when there are doctors,  scientists, legal scholars and other advocates who do great, lifesaving work and have to dodge insults and death threats for speaking out against this dangerous anti-vaccine trend. For example, Dr. Paul Offit, a very public vaccine advocate and Chair of Pediatrics at the Children’s Hospital of Philadelphia, has had to have his mail screened for explosives, and be accompanied by personal security after receiving threats following his testimony at an autism hearing. Since then he has been on the radar of the anti-vaccine cult and is a frequent target of vague and specific threats.

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Other advocates with less public personas, including parent advocates with whom I have had regular contact, also receive similarly disturbing threats and invasions of privacy. The insults I have seen flung towards very respectful, passionate people go far, far beyond mere categorization based on their political stance.

By the way, there’s no doubt about it. This is a political issue. It’s not a scientific controversy.

Let me explain, though, what I mean when I say anti-vaccine. These are the people I don’t include when I use the term:

  • Vaccine hesitant parents or parents who have simply chosen not to vaccinate because of fears about vaccine safety, but otherwise do not try to advance vaccine fearmongering. If they want to be called “non-vaxing,” “delayed/selective” or any other label, then fine, whatever. I just hope that they’re making these decisions while their kids are involved with real medical doctors or medical caregivers.
  • Vaccine safety advocates, in general, who are engaged in efforts to actually make vaccines safer. This happens to include many academic vaccine researchers, and professionals within the CDC, FDA, NIH and other oft-maligned organizations or agencies.
  • Persons or caregivers of persons with health conditions who are seeking answers about the condition, and may be privately or publicly asking questions about the role of vaccines or other drugs.

People that I do consider “anti-vaccine” or part of the “anti-vaccine movement” are those who promote fear, uncertainty and doubt (FUD) about individual vaccines and/or the recommended vaccine schedule or the vaccine program as a whole, including:

  • People who lie, distort and manipulate information in order to make parents afraid of vaccines, or to promote various “vaccine choice” causes that are based on lies.
  • People who insist, even in the face of overwhelming evidence to the contrary, that vaccines caused permanent unwanted health conditions or death.
  • People who promote conspiracies about vaccines without any evidence.
  • People who resist information about vaccine safety, deny that vaccine safety is properly understood, or imply malfeasance in vaccine research despite a lack of evidence and have a pattern of doing this even when their errors are pointed out.
  • People who say vaccines are loaded with toxins, poisons, etc, and use other frightening, emotive words to describe vaccine ingredients or procedures.
  • Doctors and researchers who make fraudulent claims, conduct fraudulent or misleading research, and especially those who profit from promoting fears about vaccines.
  • Various other quacks and businessmen who profits from vaccine fear.
  • Anyone who considers themselves anti-vaccine.

I think it’s pretty simple. Leave a comment if you think my attempts to categorize people is whack, but if you just want to whine about how it makes you feel marginalized, you’ll get no sympathy from me.

Also, check out You Might Be Anti-Vaccine If…. by MomsWhoVax

Vaccine opponents have facts, too

Vaccine opponents have facts, too, they just don’t seem to base their decisions on them.

I’ve written about my time as an anti-vax mom on my other blog. I probably wasn’t the typical vaccine opponent because, while I gleaned some entertainment from the conspiracy theories, I wasn’t much of a conspiracy theorist myself. In my view, most of the anti-vaccine rhetoric hinges on either cynicism about the government or outright conspiratorial thinking.

However, I was fascinated by vaccine science– or what I knew about it as a (at the time) sophomore pursuing a biology degree. The thing is, I knew a lot of other intelligent, creative parents (mostly mothers) who were also interested in the science, the “peer-reviewed papers” that vaccine advocates so often demand, and still chose not to vaccinate their children. It isn’t always a lack of facts, or a total disregard for them that leads to vaccine rejection. More often, it seems, it’s just decision-making based on different priorities. For me, the decision was made partially on misinformation, partially on real information, and mostly on culture, emotion and superstition.

I recently wrote:

I was intrigued by the [anti-vaccine] information I was reading, especially the speculations that there wasn’t sufficient science on disease ecology and the assertion that we were somehow cheating nature in a way that would come back to bite us.

Today, this topic– microbial ecology– still captures my attention, which explains my most recent post on this blog. This is where I praise the vaccine opponents for bringing some real, and fascinating evidence into the discussion instead of the absolute woo that’s all too common. That is, the effects of the PCV vaccine on microbe colonization in the nose and throat. Even when they bring solid evidence to the table,. the knee-jerk rejection of vaccines, and mixing good science with pseudoscience and fear, is more than obnoxious. So while I’m giving credit where it’s due, I have to insist that the anti-vaccine position is still dangerously warped.

There is a lot of evidence that vaccines have prevented infections, both mild and very serious. There is evidence that individual vaccines have reduced hospitalizations from the targeted illnesses and secondary infections. An emerging topic in research is the concern that bacterial conjugate vaccines, like PCV, is the possibility that vaccines will lead to the dominance of new species of microbes that colonize the nose and throat, and new types of infections will emerge that may make the overall impact of vaccines like these quite weak. So far, this hasn’t been observed as a significant problem, although some reported cases of ear infections caused by non-vaccine strain pneumococcal bacteria and staph that made the news, implicating vaccines as a possible cause for the shift.

In the PCV references in my last post,  I pointed out that the authors in one study specifically looked for and detected no increase in disease caused by non-vaccine strains. Not only were S. pneumoniae ear infections reduced (77%), but that contributed to an overall decline in ear infections (60%) meaning that there was no apparent, clinical illness caused by niche replacement. This study was in Israel, and from the abstract alone it was unclear which other factors were controlled for, including exposure to secondhand smoke.

There are different ways of monitoring the impact of the pneumococcal conjugate vaccines. One is by monitoring the incidence of invasive disease– like meningitis, sepsis and pneumonia. Another way is to monitor the incidence of minor illness like ear infections, either in total or specifically from strains included in the vaccine. Finally, one can monitor nasal swabs to get an idea for how the vaccine impacts colonization by the bacteria strains, but not necessarily infection.

H. influenzae (Hi) vs. S. pneumoniae (Sp), as well as S. aureus (Sa) and Sp, compete in ways that may lead to one of these other pathogens to emerge and cause illness in the absence of Sp. There has been much study on this subject, and a few plausible mechanisms determined from in-vitro studies– specifically the production of hydrogen peroxide by Sp contributing to a decrease in Hib. Yet, from nasal swabs of inoculated mice, it appeared that Hi outcompeted Sp. Hard to draw a conclusion from that. Since we can vaccinate for Hib (an invasive-disease causing strain of Hi) and 13 strains of Sp, the issues of these two competing seems kind of a moot point since cases of invasive disease from both have declined (Hib disease by 99% according to CDC surveillance).

For Sp vs. Sa,  this 2004 paper showing an inverse relationship between these organisms has been cited at least 90 times, meaning there has been a good deal of follow-up research on this topic. This 2014 paper did a follow up study, and found:

Among subjects colonized with pneumococci, the number also carrying either H. influenzae or S. aureus fell during the study and at 14 days post-inoculation, the proportion carrying S. aureus was significantly lower among those who were colonized with S. pneumoniae (p=0.008) compared to non-colonized subjects.These data on bacterial associations are the first to be reported surrounding experimental human pneumococcal colonization and show that co-colonizing effects are likely subtle rather than absolute.

In 2005, children with HIV were more likely to be carriers of S. aureus than HIV-negative children. Among children with HIV, those colonized with S. pneumoniae were not more or less likely to carry S. aureus than those who were not colonized– so S. aureus infection was independent of S. pneumoniae infection.

And in 2009, parental colonization with S. aureus was found to be an important factor in whether or not children carry the bacteria.

PCV appears to have had a significant and dramatic effect on the incidence of pneumococcal meningitis, but because of its recent introduction, it’s less clear at the moment whether or not this will have an overall impact of reducing cases of invasive meningitis, given the possibility of serotype replacement or niche replacement by another bacterial pathogen. Hib conjugate vaccine, on the other hand, has been around long enough to show a reduced incidence of Hib meningitis without a corresponding increase in bacteria meningitis from other pathogens. Of greater concern, complicated pneumonia increased over time, as a subset of pneumonia cases despite the introduction of PCV7 (prior to PCV13). This increase occurred even with a drop in cases with a bacterial cause, and a dramatic drop in pneumococcal cases. The increase in cases caused by staph appeared to be linked to a surge in MRSA prevalence. Immunization status was unavailable in the study linked above. However, the WHO assessed the growing rates of empyema in Australia and found:

…the absolute increase in the incidence of hospitalizations for empyema and for viral pneumonia (3 and 70 hospitalizations more per 106 person–years, respectively) was much smaller than the absolute decrease in the incidence of hospitalization for bacterial pneumonia (623 hospitalizations fewer per 106 person–years).

The hardcore anti-vaxers apparently trumpeted the incorrect story of “pneumonia caused by pneumococcal vaccine!” I hadn’t heard of any of this until now, probably because at the time this news came out I was a terrified young mother and just seeing words like “empyema” on my computer screen would make me an anxious mess. So, I missed it. However, as a consequence of my own tendency toward panic, I do understand why vaccine-hesitant parents who read package inserts and see scary words like “thrombocytopenia” and “encephalopathy,” would be further frightened by reports that muddy the waters and make it seem like maybe newer vaccines aren’t worth it.

As interesting as this is to geeky laypersons and some fierce vaccine critics, it is of little concern to the average parent. Every study I have seen covering this topic has indicated a need for further study and more careful methods to sort it out, but none have suggested that it’s an issue worthy of frantic urgency. It certainly doesn’t warrant ditching the vaccine program in part or in whole in the name of microbiome integrity. Anyway, the Active Bacterial Core Surveillance program reaches over 42 million people in the US and monitors bacterial infections, including treatment resistant organisms. This is one of several tools in place to pick up possible shifts in infection rates. So we have time to wait for further studies while still taking advantage of the apparent benefits of PCV 13, even though the full picture is incomplete.

I mentioned that anti-vaxers have facts, too, because these niggling topics rarely come up in those pro-vax forums made up of lay advocates rather than professionals in the field. The most dismissive pro-vax individuals miss the opportunity to learn from their opponents. Vaccine critics like to think that a lack of discussion of issues like this among pro-vax warriors online is indicative of willful ignorance or blind defense of vaccines. Thus the oft-mocked “do your research!” What they’re referring to is consumer research. The anti-vaccine crowd does not produce quality, peer-reviewed research that supports their position, though they may occasionally find some and cling to it. The reality is that none of us can study and discuss every topic in depth in the way we all might like. Then, the controversy is so heated in social media that there’s little chance for a thorough, informative discussion most days of the week.

That, my friends, is why I have this blog. Here I pretend to be part of a discussion, even though there may be no one listening.

Impact of vaccines on drug resistant microbes

Voices for Vaccines recently highlighted an opinion piece by Peter I. Hartsock, submitted to the Washington Post in which Hartsock argued that vaccines are an invaluable tool in our attempts to control organisms resistant to treatment.

A particularly important benefit of vaccination is its critical effect on the evolution of disease. A growing number of deadly maladies are becoming resistant to drugs. Every infection prevented through vaccines means less need for medical treatments for that type of infection. This, in turn, helps reduce the speed at which diseases “adapt” to and render medications ineffective.

Vaccine critical voices from the forums at Mothering.com (MDC) have questioned whether this statement is just dancing around the issues since, one person claimed, “but VACCINES are causing the same phenomenon!”*

Are non-vaccine strains, and strains that mutate to evade vaccines a problem significant enough to denounce the major successes vaccines have had?

I’m going to try to discuss these one at a time over several blog posts, since it’s a fascinating topic to me. I’ll start with the PCV vaccine.

The person I quoted above included a link to a 2007 news report about the emergence of drug resistant Streptococcus pneumoniae strain 19A, a strain that was not included among the original 7 strains of the PCV (PCV7) vaccine in 2000. This strain was being actively monitored by the time the 2007 news report surfaced, and within 2 years the PCV7 vaccine was replaced with PCV13, which covered strain 19A and 5 other strains that had not be included in PCV7.

By 2013, a study in Israel showed a total decrease of 77% of cases of ear infections caused by S. pneumoniae, and 60% decrease in ear infections of all types, without noting any increase in ear infections caused by non-vaccine strains of S. pneumoniae. This is important because the vaccine protects against only 13 predominant forms of 90 total known strains. The concern has been that other strains will fill the niche when those 13 vaccine strains are eliminated. So far, this hasn’t been an issue.

A study conducted in 2011 in the US specifically monitored the impact of vaccines on antimicrobial resistant strains of S. pneumoniae. Infections with microbial resistant strains were reduced by 64% for children under 5 and 45% for adults over 65 following the introduction of PCV7 and the recent (at that time very recent) transition to PCV13.

Since S. pneumoniae is a bacterium that has been a common cause of minor infections as well as serious, invasive illness, it has played a major role in clinical antibiotic use in the developed world. The reduction of these infections by antibiotics, as I’ve highlighted, have reduced the need for antibiotics and thus offer hope to reduce the further development of antibiotic resistance. Other vaccines that prevent primary bacterial infections are Hib and meningococcal vaccines.

Vaccines don’t just play a role in reducing these primary infections, but they also eliminate secondary bacterial infections following preventable viral infections such as chickenpox, measles and influenza.

While there are some potential concerns about tricky organisms mutating to evade vaccines, specifically influenza, and possibly pertussis, these concerns are minimal compared to the dramatic successes of vaccines in preventing infections and thus reducing drug resistance.

A pro-vax Facebook group reports suspected medical neglect

Several days ago a mother of a 15-month old child in Canada posed a question with a lengthy explanation of her child’s situation in an anti-vax, natural health group on Facebook. The mother asked “Does anyone have experience treating pneumonia naturally?” Her story was featured on the public page Things Anti-Vaxers Say (TAVS), and people on that page were rightfully outraged. The story went like this: she had already taken the child to the doctor, got a diagnosis of bacterial pneumonia and a prescription for antibiotics, but for two days she had chosen to give various alt-med remedies rather than the prescription. She now wanted to bolster her confidence in rejecting the meds. pneumoniaApparently a number of people who commented in the alt-med group suggested that the mother should definitely give the kids antibiotics (good for them). Bacterial pneumonia in a 15-month old is not something to play around with, they said. Meanwhile, outraged persons on the pro-vax side promptly reported the mother’s confession of intended medical neglect to the proper authorities in her region. TAVS received a response from the area’s child services thanking them for the report. Subsequently, a group that hosts similar discussions warned its members to be more discrete with their questions so as not to “incriminate” themselves, and also, a reminder that they shouldn’t try to give medical advice over the internet. incriminate It is tragic.

It is tragic because the anti-vax group wasn’t issuing a reminder that parents should seek medical advice from actual medical professionals with the skills and experience to examine their children. The advice was merely: don’t talk about criminal neglect in a way that might incriminate you. These parents, for the most part, are probably assuming that their remedies will save their children and so in the absence of their own confessions of willful neglect, there will be no evidence of wrongdoing. Should their attempts to play doctor fail, and the child’s condition degrade to the point where the parent’s concern overrides the need to feel satisfied with their alt-med experimentation, then the hospital or morgue where the child ends up will certainly have substantial evidence of willful neglect with or without the parent’s confession. In some cases, however, that may not be enough to hold the parents accountable. Ultimately, it’s the child who bears the consequences so the only thing that can truly help is timely intervention.

I’ve participated in anti-vaccine internet forums where parents have a paranoia complex so severe that many think it would be best to lie to a doctor about a child’s vaccination status rather than confess that the child is not vaccinated. To them, the perceived risks of that confession were estimated to be higher than the risks of giving an incomplete, inaccurate medical history. This kind of reasoning only makes sense to comfortable liars whose need to feel secure with their poor decision supercedes concern for their child’s life. A delay in proper diagnosis of some vaccine preventable illnessses can be the difference between life and death.

Anti-vax and alt-med parenting groups operate with a cult-like secrecy and paranoia. While many will discuss their ideas openly, they tend to be hush hush about the sources they rely on for their information, knowing that their sources won’t be accepted as legitimate– or their interpretation will be shown to be wrong. Amongst their own, they are fully comfortable exploring the wildest hypotheses, subjecting their children (and sometimes their unsuspecting spouses) to dangerous experimentation, and badmouthing the organizations and government agencies that attempt to set standards for medical care and parenting.

As a homeschooling mom and a Christian, I’ve been exposed to a bizarre world of medical care denial in which vaccine rejection is just one slice of that pie (albeit a large one.) I’ve had sincerely concerned parents warn me about the dangers of CPS, the need to join the Homeschool Legal Defense Association (HSLDA) to protect myself, and repeat fairytales about CPS kidnappings that occur “because the baby was breastfed!” or “because the mother had a homebirth!” or “because the parents didn’t vaccinate their children!” or “because we homeschooled!”

The fantasy stories that compel homeschooling parents to pay hundreds of dollars a year for legal insurance are usually either originated or recirculated by the same organization that stands to benefit from this fear. The mythical CPS is a frightening, all-powerful arm of government running madly across the landscape hunting children to devour and families to destroy. I’m not saying it doesn’t happen. It’s a bureaucracy as vulnerable to abuse and indifference as any other.

I’ve tried to gently respond that I’ve spent many hours in the juvenile courts as a child advocate. I’m a mandatory reporter. I’m trained to know what abuse and neglect look like, and I am aware that most investigations are based on reports of mere suspicion and do not lead to any further action. I know CPS workers and they are diligent, but overworked professionals. They don’t want to harass families for no reason. They don’t have the time. They don’t have the energy, and despite the myths, most of them don’t have any malice for good parents, religious parents or parents who are just a little eccentric.

When parents are refusing to treat their children for serious, diagnosed conditions like bacterial pneumonia and they are crowd-sourcing medical advice from people who have no medical training, then any action taken by CPS on behalf of the child would be justified. After all, these parents killed two young children by refusing to get medical care for treatable pneumonia. Pneumonia kills. Antibiotics should be used and prescribed cautiously, and if a doctor prescribes them for a known bacterial infection of the lungs, then that’s a clue that they’re probably necessary. If CPS didn’t respond to reports of this type of medical neglect, then they’d be failing in their duties.

I’m glad that groups like TAVS took the steps necessary to at least try to protect this child. While sometimes the groups that mock anti-vax parents can go to extremes in their ridicule, this is one good example of how valuable such a group can be in helping to protect children who are truly the victims of their parent’s poor decisions.