Like it or not, the controversy over vaccines continues unabated. Consider Vermont. The state legislature is locked in a heated debate over whether to end the "philosophical exemption," which gives parents a right of refusal for avoiding immunizations when they enroll their children in school or child care.
Vermont already has one of the highest rates among states in which kindergarteners have been exempt from vaccines, according to an Associated Press analysis, which found its 6 percent rate trailed only 7 percent in Colorado and 9 percent in Alaska during the 2010-2011 school year, the latest year for which data is available.
Meanwhile, Christine Finley, immunization program manager at the state Health Department, tells the AP the percentage of kindergarteners with all required immunizations fell to 83 percent in 2010 from 93 percent in 2005. In her view, the high exemption rate accounts for recent outbreaks of pertussis, or whooping cough. The Vermont Coalition for Vaccine Choice says the decline is exaggerated, since kids are counted as unvaccinated if they miss any of 20 required shots.
As the legislative session draws to a close, lawmakers are at an impasse. The state Senate voted 26-4 last month to eliminate the philosophical exemption, while the House voted 93-36 this month to keep the status quo. If the bill dies, Verrmont will remain among the 20 states that allow some form of philosophical exemption from required childhood immunizations, the AP writes. All but a handful of states offer religious exemptions, and all allow medical exemptions.
Vermont House Speaker Shap Smith says the state motto, "Freedom and Unity," is in play. "It's a balance between individual rights and our obligations to each other in society," he tells the AP. One lawmaker who wants to end the exemption complains parents who fail to immunize their children are irresponsible. "The question is whether they have the right to endanger other children in the school setting," says George Till, a Democrat and obstetrician-gynecologist.
Meanwhile, Vermont Governor Peter Shumlin is siding with the House plan for more education on immunization rather than a Senate push to remove the exemption. The AP notes this is a flip flop from the position his own health commissioner pushed for earlier this year.
"I do not believe that, in the end, the government should dictate to parents what inoculations their kids have to get in order to get a public education in Vermont," he tells the AP. He wants Vermont to "start with more education, to separate the myths that you read about on the Internet with the facts that health care providers will give you on this."
vaccine pic thx to lulu on flickr
12 Comments
The increase in exemptions that the department of health is fussing over came about in 2008 when chickenpox and hep b were added to the schedule. Apparently a small percentage of VT parents had questions about those two vaccines.
VT has been ranked the healthiest state in the U.S. with a low, and dropping rate of infectious illnesses. Puzzling...
http://www.reuters.com/article/2011/12/06/us-states-ranking-idUSTRE7B52DP20111206
"Vermont has again been named the healthiest state in the nation, topping the list for a fifth straight year thanks in part to a high rate of high school graduation and low incidence of infectious disease."
I don't think the drive to remove the philosophical exemption in VT has anything to do with a health emergency.
Potency of the vaccine matters - for instance, my dog caught distemper 3 weeks before the next shot was due. Then it turns out the the strain in the 'hood had morphed and a new *super* version was going around - which 6 month shots instead of yearly at top potency beat back the strain into submission...
So, yes, a 10% population is not the danger in and of itself - it's the way it could jump to those who did not receive the correct potency. That's why we continue to have new forms emerging - the "super" version, so to speak.
And then there's the sub-group that received the correct potency, but it did not immunize them because of genetic variations. That group also contribute to the development of super-strains.
Health care delivery is a regional enterprise. Homelessness and large numbers of refugees from weather, war or volcanoes, etc. complicate an already complicated situation. So saving $$$$ on labor, but adding in globalization - days-to-delivery issues and uneven manufacturing quality - and the efficacy of vaccines will appear to be controversial when it's the business model, so to speak, that is a "fail".
So sure, the 85% of us that got vaccinated will survive any epidemic, but I am not really comfortable with the idea of large swaths of children being exposed to potentially life threatening diseases because their parents made an uninformed and wholly irresponsible medical decision. Let alone those that are unvaccinated for medical reasons being exposed because of other's poor choices.
And the one thing that is a biological fact is that bacteria and viruses morph. Which means that there will always be a need to adapt all measures when needed - intervention, prevention and quarantine.
Since it appears from David's comment that herd immunity is quite variable, it's probably best to get all kids vaccinated. If the parents don't like it they can move to Wisconsin.
We are all looking for the best way to protect our kids. However, the current CDC schedule calls out 48 vaccine doses for a child before they reach the age of six. Well over half are before they reach the age of two. If you were born in 1983, the total dose count was 23. If you were born in the sixties, it was less than 12. So I ask you, with all these additional shots, are kids healthier that they were a generation or two ago?
Kids today get a hepatitis B shot at birth and multiple boosters afterwards. HepB is a sexually transmitted disease that infants have zero risk of contracting if their mother does not have it. Also, the immunity wears of by the time they are teens when it might actually do some good. Children today are vaccinated against chicken pox, a harmless disease in kids. Children now get yearly flu shots (most of which still contain mercury). Why? When did flu become something other than a normal childhood malady? Kids don't die from the flu, the number of pediatric deaths from flu is miniscule. Rubella almost never has complications in children. While you might make a case it is needed to protect pregnant women against congenital rubella syndrome in the fetus, lets be honest and admit the shot is not protecting the recipient, it's protecting someone else. Vaccines have morphed from being a tool to protect against deadly diseases to a pharma cash cow that protects against inconvenient diseases. If you want to use them that's fine, but for the rest of us it is our decision.
If vaccines were risk-free, we would not be having this discussion. They are not, they are an invasive medical procedure that entails risk. As such, recipients and parents of minor recipients are entitled to informed consent. The only way to protect that right is to maintain the unconditional philosophical exemption. Those who are afraid of my selectively vaccinated children can get their own shots, no one is stopping them.
Speaking of that, how many of the adults demanding our kids be treated as pin cushions get the shots themselves? Many of the pediatric vaccines are available in adult versions, why must children bear the brunt of herd immunity?
They probably are healthier... At least we see far fewer cases of meningitis, serious invasive pneumococcal disease, bacteremia/sepsis, and even ear infections. Hospitalizations and ER visits for rotavirus are significantly decreased. Neurologic impairments specific to vaccine preventable illnesses are fading in the memory of older MDs, and have never been seen by newer graduates.
You are dead wrong to assert that flu and chicken pox are "routine" or "harmless." Both can and do kill children. Chicken pox can lead to neurologic impairment. I think even wikipedia could show you the error of your thinking; if not, certainly a look at the CDC site could.
You are also incorrect in your assertions about the duration of immunity provided by Hep B vaccine started in children under 6 months of age. Current information indicates that immunglobulin protection lasts at least 20 years, and likely longer, but that cellular immunity may, in fact persist indefinitely. Studies are on-going. Note that routine Hep B vaccination began in 1992 (with thimerosol) and paused briefly in 1999 (until the thimerosol-free vaccine was available). So a 20 year follow-up would only be possible at this time. Also, It is two "boosters," not "several." it is also possible to receive the second and third doses in a combination vaccine minimizing the number of "jabs."
Besides, even my cynicism about the medical-industrial complex would lead me to believe that if Hep B immunity did, in fact, erode prior to adolescence, we would by now have a vaccine schedule for boosters starting at age 8-9 years.
A number of years ago, the pertussis vaccine was changed to an "acellular" formulation. This made adverse reactions less common, but unfortunately didn't increase the immunogenicity of the vaccine. Even with "wild-type" pertussis infection, immunity against this particular pathogen appears to decrease over time. We are learning that while most adoolescents who contract pertusis recover, they place the very young, elderly and frail patients at risk of infections they can not overcome. Pertussis in a young infant can be associated with the baby simply stopping breathing (apnea). Sometimes this is the only symptom. If the infant survives the initial episode and gets supportive care (usually an extended period on a ventilator), the apnea episodes will persist for weeks - It makes for a difficult decision on when to discharge the patient, and for some very frightened parents... Been there, done that.
Counting "doses" is not an accurate means to compare schedules. There have been changes in the schedule over time based on changes in formulation or greater understanding of the likelihood/duration of a vaccine response. There have also been changes in the formulations of vaccines so that several are combined into a single injection. Look up Pentacel or Pediarix, to name a couple. These combinations work as well for providing immunity as separate shots, with no added risks and several fewer injections.
The US recommendations currently provide routine vaccination for 15 preventable disease causing pathogens for young children. A 16th (meningococcal vaccine) may be needed in certain individuals. That is more pathogens than we used to be able to vaccinate against (to avoid the potential complications of the actual disease). In early adolescence, we add two more pathogens to the list of preventable disease causing agents.
We no longer vaccinate for smallpox, and someday I hope we will not need to vaccinate for polio (not there yet, but maybe soon).
I might quibble over the need for the rotavirus vaccine in a country with excellent tertiary care facilities - of course this is an oral vaccine so most parents don't object to it. Most kids here are sent to daycares which are an excellent places to acquire diarrheal diseases. I might also wonder about the necessity of Hep A vaccine, particularly outside of areas where this (self-limiting, and rarely serious) disease is endemic. I can feel a little better about Hep B vaccine since this virus can lead to chronic disease, cancer and/or liver failure (given the popularity of tattoos in the current generation of parents, I wish we had a Hep C vaccine). Yes, Hep B can be transmitted sexually, but it can also be transmitted through blood contact or even contaminated medical equipment - unfortunately, you can't be sure your children will be protected from these risks until they are teens. (I could also wonder why you think it is acceptable for teens to be sexually active - not all are. Of course we also know that some young children do not really get to choose when they become sexually active.)
But so far, I've only come up with quibbles about three out of the 15 diseases against which we routinely vaccinate. Since the Hep B can be given in a combined shot, dropping Hep A would save two sticks and dropping rota would save none (it is oral).
For every other one, the diseases carry serious risks of death or significant long-term (often neurologic) consequences. Sure, for rubella, the protection is for the unborn children, but funny enough, you often find pregnant women hanging around with kids, some of whom haven't been vaccinated. If you've ever seen congenital rubella (there are still some survivors though they are mostly institutionalized in my experience) you would not call this devastating complication an "inconvenience." Increasingly, there is also a risk that these previously common diseases will not be recognized by clinicians because they have become (thankfully) rare.
I can agree with you on another thing. Informed consent is vitally important concerning vaccinations. It is important for anyone making a medical decision affecting their health or another person's to get accurate information from an educated, objective professional. For example, I know that our flu shots for children do not contain mercury in any form. Before this year, our "young kid" flu shots had been thimerosol free for several years. This year they were all thimerosol free. Getting information from the internet is not a good choice. After all, who can accurately assess the validity and accuracy of my comments relative to yours Jeff?
I would finally add that pediatricians are a good source of objective information about vaccines, certainly everyone of us had the opportunity to pursue more lucrative areas of medicine - pediatricians remain at the bottom of the pay scale among medical specialists. Few of us actually complain about that, but universally we are committed to the health and well-being of children. And no, we don't get rich off of vaccines. In fact in some areas, vaccine payment is so low that some practices lose money giving vaccines by the time all of the costs are accounted for. We don't get paid extra to counsel 'vaccine-refusers,' and the unfortunate truth is that we know some parents have deciding their own "truth" about vaccines before we begin a discussion. Removing ear wax or draining an abscess pays far better than giving a vaccine.
Unfortunately, because of the efforts of a few over-zealous individuals the perceived risks of vaccines are greatly exagerated compared to their actual rates of complications. Objectively, parents should be far more fearful of antibiotics and over-the-counter remedies than vaccines. Weirdly, vaccine-objecting parent's are not always also concerned about side-effects and complications of these other treatments much more likely to do harm. And, don't even get me started on the risks of antipsychotics in children, and the eagerness of some parents to get or keep their child on these medicines...
It is still far more dangerous to put your child in a car than to give them the benefit of protection from vaccine preventable diseases. You can read about both in the April 20, 2012 MMWR from the CDC.
Finally, Jeff, you should also understand that I'm not afraid OF unvaccinated children, I'm afraid FOR unvaccinated children.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2732098/
You can also find there the number of claims of injury related to vaccines and the number of claims found justified, and paid. This program is a system for compensation of injury attributed to vaccines so, I'm not sure what Mykidsma means when stating that there is "no one liable to help..." Now for those who are paying attention, the data there indicate (with the exception of four of the past 20+ years)only a few hundred claims are filed each year. Many are found to be not likely to be related to a vaccine, but even if one assumed that all actually were due to some vaccine, the rate of claims is dwarfed by the number of vaccines given, AND by the number of actual cases of vaccine preventable disease reported annually.
The likelihood of injury or death due to a car accident on the way to or from the doctor's (or public health department) visit for a vaccine is still greater than the risk of the vaccines themselves. The outcomes for the diseases are far worse than the risks of the vaccines. Death, disability, and injury are orders of magnitude more likely with the native disease than with the vaccine. This is exactly why vaccination became an accepted public health strategy as far back as the early 1800s - starting with Jenner's work to vaccinate with cow-pox innoculum to provide immunity to small pox.
We don't know Benjamin Rush's or Hugh Williamson's views on vaccination. Both were founding fathers an physicians. Rush was a great enthusiast of blood-letting and he developed a constipation "remedy" containing such a high level of mercury that traces can still reliably be found in revolutionary army encampments. Williamson, among other things, imported medicines to the colonies. So I suppose he would be among the first Americans in the pharmaceutical industry. I'm not sure that relying on the founding fathers for medical decision making is a very good idea, and I don't believe that wrapping oneself in the constitution is an adequate defense against very clear scientific evidence and progress in disease prevention.
In most instances rates of death due to vaccine preventable disease have fallen by more than 90% since vaccines have been used. I'm fairly certain that since some of the founding fathers lost children and other family members to vaccine preventable diseases they would enthusiastically embrace the great scientific advancement represented by finding a way to use natural, God-given disease fighting mechanisms in the body to prevent a disease to which the person had not (yet) been exposed.
If one prefers to stick with 18th century ideas on liberty and economics, I'm fairly certain that Smith's "Wealth of Nations" acknowledges the link between the health and productivity of workers in a society and the economic success which can be attained.
Yes, public health measures can be intrusive - witness the TB sanatoriums of the pre-antibiotic era. The ability to quarantine individuals against their will is still a recognized and sometime needed protection for the general welfare. This is evidence that sometimes the right to make "informed health decisions" is NOT a basic human right. There are now more than a couple of cases of HIV infected individuals who knowingly sought to spread the infection to others - in some cases to as many as possible. I would not defend their "basic human right" to do so.
Public health measures also ensure proper sanitation and clean water, and are the best value in medicine per dollar spent. Vaccination rates (like public sanitation) correlate to economic prosperity. It is fascinating to me to observe that children of immigrants from Mexico and points south virtually never fail to fully immunize their children. The worst vaccination compliance rates are among the poorest native born US residents who have obvious barriers (basic transportation, health literacy, etc.) and the most "sophisticated," typically caucasian families - many of whom simply refuse to understand the science. These "vaccine intelligentsia" are typically the same folks who get their necks bent out of shape when confronted with facts about vaccines not convenient to their world view or political philosophy, but who I also often find are quick to rush to the doctor's office for an unneeded antibiotic to treat a common cold.
I too am concerned about "corporate greed" and it's corrupting influence on health decisions. I'm a vocal advocate for effective and correct use of medications and medical interventions. I have been critical (within my professional society and frank with my patient families) of specific vaccine strategies. However, I am far more concerned about the "corporate greed" motivating development of unneeded, unsafe or unhelpful "treatments" for (sometimes invented) disorders than I am with efforts to minimize the harm of dangerous infectious diseases through vaccines.