Science trumps candidates: MMR vaccine, shot schedule safe
Will ‘dangerous’ debate talk hurt public, HCW vaccination rates?
As vaccine-preventable diseases continue to resurge and threaten both patients and healthcare workers, 23 million television viewers — an all-time record for CNN — recently heard reckless comments on vaccine safety by men who aspire to the highest office in the nation.
Three Republican presidential candidates — two of them physicians — made comments at the Sept. 16 GOP debate that either gave new life to the old lie that vaccines are linked to autism or suggested that childhood shots are unsafe because too many are given at the same time.
The comments were immediately condemned by the medical community, with the American Academy of Pediatrics (AAP) calling them both false and “dangerous.” However, there is some concern that the high-profile discussion will reinvigorate the anti-vaccine movement in the U.S. and give pause to healthcare workers who are being strongly urged to overcome historical resistance and receive all recommended vaccines.
Indeed, it was the resurgence of measles — in part because people were shunning the MMR vaccine because of fears of autism — that prompted the American Nurses Association to recommend that nurses and their healthcare colleagues be immunized for all recommended vaccines. (See Hospital Employee Health, Oct. 2015.) After the considerable fallout following the debate, the ANA reminds healthcare workers that science overwhelmingly supports the current medical consensus about vaccines. “ANA’s hope is that healthcare professionals are ‘smarter’ and seek to research information so that they can be advocates [of vaccine safety],” says Ruth Francis, MPH, MCHES, program specialist in the ANA’s nursing practice and work environment department.
In any case, the medical community could not let the debate comments stand, and some of the varied and passionate responses included a pediatric infectious disease physician’s vivid description of sick children before many vaccines were available. (See related story in this issue.) Other rebuttals came from the highest levels of public health.
“Study after study has concluded that there is no risk [or connection] between vaccines and autism,” said Tom Frieden, MD, director of the Centers for Disease Control and Prevention. “There is, though, a very serious problem of autism. The discussion of vaccines and autism unfortunately has, at times, interfered with our ability to study further what is causing autism so we can both prevent it better and provide better services to the children and families who have autism.”
Frieden’s comments were made one day after the debate at a Sept. 17 influenza meeting and press conference held by the National Foundation for Infectious Diseases (NFID). The director made the subtle point that the CDC is the agency collecting reports and documenting the increase in autism, leaving unsaid the question of why would an agency try to “hide” or deny a link between vaccines and autism while simultaneously reporting an increase in the childhood disease. In terms of the scheduling of childhood shots, Frieden said that is discussed and set in open meetings by the CDC’s Advisory Committees on Immunization Practices (ACIP).
“[ACIP] works in a completely transparent fashion,” Frieden said. “All of the meetings, all the documents are open to the public. There are individuals and entities represented on ACIP from all sectors of society, including patient groups. And this is not just the most effective way of setting vaccine policy. It’s a model for countries around the world. Because let’s be frank — for most vaccines, there are some people who think that there’s something bad about them. And there is hardly a vaccination program that’s been run in any country, anywhere in the world, ever, that hasn’t had some rumors circulating about it. The best disinfectant for rumors is transparency.”
Fear and prejudice
Shortly after the debate, the Autistic Self Advocacy Network issued a statement that said, “Politicians continue to talk about an autism epidemic — despite the fact that science suggests that autism has always existed at its current rate within the general population. Autistic people are not new — and neither are our unmet needs. … Vaccinations do not cause autism — but the use of autism as a means of scaring parents from safeguarding their children from life-threatening illness demonstrates the depths of prejudice and fear that still surrounds our disability.”
The vaccine safety issue was originally seized on by some to explain the dramatic increase in autism over the last few decades. However, it appears that much of this trend has been due to changing definitions — “diagnostic substitution” — that has increased the number of intellectual disabilities defined as autism. This type of surveillance artifact accounted for a 64% increase in autism diagnosis from 2000-2010, researchers recently concluded.1 However, critics have pointed out that diagnostic substitution does not explain all of the increase, and vaccine researcher Paul Offit, MD, of the Children’s Hospital of Philadelphia, has observed that the autism issue may cast a shadow over vaccine safety until the real reasons for the disorder are completely understood. Complicating matters, the CDC is expected to tighten the autism definition in the near future, winnowing out other intellectual disabilities that have heretofore fallen under the broad category. As employee health professionals are well aware, a more restricted clinical definition will invariably lower the number of reported autism cases. If this occurs, we should see another round of controversy as critics accuse the CDC of manipulating the data.
All the while, the research showing that vaccines do not cause autism continues to accumulate. A study published this year in the Journal of the American Medical Association found no link between MMR vaccine and autism after looking at thousands of patients.2 There was no link even among children already at higher risk for autism due to an existing diagnosis in an older sibling.
“We were able to follow over 95,000 children from birth to at least five years of age.” says lead author Anjali Jain, MD, a medical consultant with the Lewin Group in Falls Church, VA. “We then looked at these kids to see which ones were vaccinated with MMR vaccine during that time period. We also looked at which kids developed autism spectrum disorder during that time period. We were able to compare their risk of developing autism relative to them having received the MMR vaccine. We found there was no harmful association between the receipt of the vaccine and development of an autism spectrum disorder.”
Trump links autism, vaccines
What was actually said at the Sept. 16 GOP presidential debate to prompt all this reaction?
Candidate Donald Trump said, “Autism has become an epidemic. Twenty-five years ago, 35 years ago, you look at the statistics, not even close. It has gotten totally out of control. I am totally in favor of vaccines. But I want smaller doses over a longer period of time. …[Y]ou take this little beautiful baby, and you pump — I mean, it looks just like it’s meant for a horse, not for a child. We’ve had so many instances, people that work for me. Just the other day, two-and-a-half years old, a beautiful child went to have the vaccine, and came back, and a week later got a tremendous fever, got very, very sick, now is autistic.”
Candidate Ben Carson, MD, a pediatric neurosurgeon, rejected the autism-vaccine link. However, he took a conciliatory tone that some found far too tepid when the leading candidate had just made a statement that is patently false and potentially life-threatening by justifying parents who deny vaccines to their children. “The fact of the matter is we have extremely well-documented proof that there’s no autism associated with vaccinations,” Carson said. “But it is true that we are probably giving way too many [vaccines] in too short a period of time.”
Candidate Sen. Rand Paul, (R-KY), MD, an ophthalmologist, then added: “I’m all for vaccines. But I’m also for freedom. I’m also a little concerned about how they’re bunched up. My kids had all of their vaccines, and even if the science doesn’t say bunching them up is a problem, I ought to have the right to spread out my vaccines a little bit at the very least.”
Theater of the absurd
The physician candidates should have rebuked Trump more forcefully for the autism comments and only confused the issue more by endorsing the false notion that there is some risk to children due to the timing of the immunizations, says William Schaffner, MD, longtime vaccine advocate and professor of preventive medicine at Vanderbilt University School of Medicine in Nashville.
“First, there is no doubt that there is no connection between vaccines and autism. That’s number one and must be stated strongly,” he tells HEH. “It is disheartening that two physicians were part of that debate and did not strongly make the point that vaccines are not associated with autism. Some of that was said, but it was not said with the explicitness and the force needed.”
Suggesting that there is a link between autism and vaccines has now been so thoroughly discredited that Trump’s comment should have been treated with the absurdity it deserved, Schaffner notes.
“If one of the candidates had said that the moon is made of cream cheese I think it could have been said by the other candidates, ‘No, that is not correct,’” he says. “‘We now have ample information brought back by the astronauts that the moon is essentially a great big rock. It is not made of cream cheese.’”
Though his equivocal tone could have been more about politics than medicine, Carson did at least refute the autism link. However, he then doubled down, as did Paul, on the pediatric immunization schedule.
“The conversation slipped into the issue of stretching out the routine childhood immunization schedule and that’s where the train went completely off the rails,” Schaffner says. “Because those physicians offered commentary that seemed to support stretching out the immunization schedule, for which there is no good reason, no evidence and it only keeps children susceptible to the diseases the vaccines are designed to prevent for longer periods of time.”
This contention was born out by an Institute of Medicine (IOM) report that concluded, “Upon reviewing stakeholder concerns and scientific literature regarding the entire childhood immunization schedule, the IOM committee finds no evidence that the schedule is unsafe. The committee’s review did not reveal an evidence base suggesting that the U.S. childhood immunization schedule is linked to autoimmune diseases, asthma, hypersensitivity, seizures, child developmental disorders, learning or developmental disorders, or attention deficit or disruptive disorders.”3
However, it is somewhat understandable why parents may be concerned that the timing and number of shots may be harmful. They are not, the IOM concluded, noting that the schedule (in 2013) protects children from 14 pathogens by inoculating them at the time in their lives when they are most vulnerable to disease. Under this schedule, which applies to those younger than 6, children may receive as many as 24 immunizations by their second birthday and may receive up to five injections during a single doctor’s visit, the IOM reported. Existing mechanisms to monitor vaccine safety, including several surveillance and reporting systems by CDC and the Food and Drug Administration, provide a safety net, the IOM added.
Another IOM report was cited at the aforementioned NFID meeting, as Wendy Sue Swanson, MD, a pediatrician, said the institute reviewed over 1,000 studies and found no link between vaccines and autism.4 “[Likewise], we have not a single study that demonstrates spacing out or delaying vaccines provides any benefit,” she added.
Swanson then read a statement from the AAP on the GOP debate: “Claims that vaccines are linked to autism, or are unsafe when administered according to the recommended schedule have been disproven by a robust body of medical literature. It is dangerous to public health to suggest otherwise. There is no ‘alternative’ immunization schedule. Delaying vaccines only leaves a child at risk of disease for a longer period of time; it does not make vaccinating safer. … Vaccines are one of the safest, most effective and most important medical innovations of our time.”
That said, the IOM vaccine report did find some adverse reactions associated with some of the routinely administered vaccines, particularly for varicella (chickenpox). (See related story in this issue.)
As previously reported in HEH, a key factor in the erroneous autism-vaccination link was the publication of a later-retracted study in Lancet that falsely suggested MMR (measles, mumps, rubella) vaccine administration triggered onset of autism in children.5 However, there has been longstanding resistance to vaccines among both patients and healthcare workers that has nothing to do with autism.
Many trace this back to the 1976 swine flu debacle, when a pandemic to rival the 1918 Spanish Flu was thought to be on the verge of an outbreak in the U.S. The 1976 H1N1 “swine flu” pseudo-pandemic was a public health disaster, as the feared flu never materialized and a newly developed vaccine given to 40 million people was linked to paralysis and fatalities due to the rare autoimmune disease Guillain-Barré Syndrome (GBS). There were several hundred cases of GBS that included a reported 25 deaths, prompting the enduring observation that the vaccine killed more people than the disease did (1 death, 13 hospitalized). In the aftermath, the director of the CDC was replaced and President Gerald Ford — who was photographed getting the swine flu shot to motivate the public — lost the 1976 election.
The level of GBS seen in 1976 has not been found with a seasonal flu vaccine, but public health officials cannot rule out that a small number of GBS cases may be occurring annually in those immunized.
“Safety monitoring of seasonal inactivated influenza vaccine (IIV) over the course of many years has not detected a clear link to (GBS),” ACIP stated this year.6 “However, if there is a risk of GBS from current IIV, it would be no more than 1 or 2 cases per million people vaccinated. This is much lower than the risk of severe influenza, which can be prevented by vaccination.”
Every year about 3,000 to 6,000 people in the United States develop GBS whether or not they received a vaccination — that’s 1 to 2 people out of every 100,000 people, ACIP noted.
REFERENCES
- Polyak A, Kubina RM, Girirajan S. Comorbidity of intellectual disability confounds ascertainment of autism: implications for genetic diagnosis. Am J Med Genet B Neuropsychiatr Genet 2015;168(7):600-608.
- Jain A, Marshall J, Buikema A, et al. Autism Occurrence by MMR Vaccine Status Among US Children With Older Siblings With and Without Autism. JAMA 2015;313(15):1534-1540.
- Institute of Medicine. The Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies. Report Brief. Jan. 16, 2013: http://bit.ly/1M0aN1V.
- IOM. Adverse Effects of Vaccines: Evidence and Causality. August 25, 2011: http://bit.ly/1YnWZrn.
- Editors of The Lancet: Retraction—Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 2010;375:445.
- CDC. ACIP 2015-2016 recommendations. Seasonal Influenza Vaccine Safety: A Summary for Clinicians: http://1.usa.gov/1jw60yE.
As vaccine-preventable diseases continue to resurge and threaten both patients and healthcare workers, 23 million television viewers recently heard reckless comments on vaccine safety by men who aspire to the highest office in the nation.
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