Having Too Many Vaccines: We Should be So Lucky

At last night’s Republican’s presidential candidate debate the vaccine issue arose. I believe that infectious diseases are worth talking about in these types of forums because the government has an important role in keeping its citizens safe from infectious disease. However, when vaccines are discussed by presidential candidates the exchange often proceeds as if there actually is a question about their benefit.

Often, the media continually dangles these red meat questions in front of candidates who apparently care less for the truth than they do pandering to people whose votes I would never want. Last night Donald Trump delivered answers that were concerning (I thought it was cool that the Washington Post dug out an old quote from me on the topic for their coverage).

While Dr. Carson explicitly—and thankfully—rejected the false notion of any link between autism spectrum disorder and vaccines, he did give credence to the idea that there are too many vaccines administered in too short a time with which Mr. Trump agreed.

Make no mistake, Dr. Carson is a world-class pediatric neurosurgeon who has advanced his field immeasurably and, as a physician, I deeply respect his unequivocal achievements. However, on the issue of too many vaccines over too short a period, the evidence clearly does not support Dr. Carson's position--though his statement regarding the relative importance of certain vaccines based on the severity of the disease they intend to prevent is valid (and why vaccines such as the influenza vaccine are not mandated by government schools).

While it is true that the vaccination schedule has become increasingly more extensive and that is something I am thankful for. We now have vaccines against human papillomavirus, pneumococcus, hemophilus, rotavirus, varicella, and meningooccus—diseases that children, and adults, no longer have to fear. I actually wish there were more vaccines to administer to children and to adults.

It must be remembered, however, that though there are more vaccines routinely administered they are of such purity that the load on the immune system of all of them combined is less than what was in the once routinely administered smallpox vaccines. Moreover, a child’s immune system is literally bombarded with foreign invaders, foreign materials, and myriad challenges that our current high purity vaccines pale by comparison.

The immunization schedule is not divined from tea leaves, it is made after rigorous deliberation by medical professionals who weigh mountains of data on immunogenicity, safety, and epidemiology. Vaccines have transformed our children into bionic $20 billion men and women and, until more diseases meet the fate of smallpox, the more vaccines the better.

If You're Going to Say Something, Make it Matter

Carly Fiorina was the CEO of a major technology company whose products aimed to improve human life. In that role she was an advocate of innovation and technological process. While most people think of electronic devices and space technologies as synonymous with innovation, vaccines are indisputably on par with such conventional examples as they have transformed the life of the average human tremendously. Indeed, most advances in public health from sanitation to disease detection are the result of technological advances.

Accordingly, I was shocked to see Ms. Fiorina countenance the positions of those who seek to endanger children by prohibiting vaccination against diseases that remain clear and present dangers in this country.

While it has become commonplace to hear politicians and public figures of all political persuasions make statements that cast unwarranted doubt on vaccines, it is inexcusable for someone of Ms. Fiorina's stature and she knows it (and Governor George Pataki correctly pointed out). Hence, her nuanced position which affirms the rights of school operators to exclude the unvaccinated.

Further when Ms. Fiorina references esoteric vaccines it is clever trick that allows her to play both sides of the issue. When I hear that term "esoteric vaccines" the vaccines against yellow fever, Japanese Encephalitis, smallpox, and anthrax spring to mind. However, my context is radically different from that of the average voter she is attempting to court who may erroneously think of the vaccines against human papilloma virus, hepatitis B, and chickenpox as "esoteric."

It should be an asset to a candidate to be pro-technology and all embracing of a tool that has literally added decades to the lives of all humans, not something that requires spin. It is never a good thing pander to the primitive to be a viable candidate.

It is only through an intransigent defense of vaccines that all vaccine-preventable diseases will become esoteric.

The Availability Heuristic, Vaccines, and Keeping Children Safe

"I just want to be safe."

That's what a mother of an infant told me today after she brought her child to the emergency department after he possibly ingested some glass from kitchenware he broke. Today was one of the days I do a shift in the ED in order to keep my emergency medicine skills and knowledge base active (I originally trained in both internal and emergency medicine before embarking on fellowships in infectious disease and critical care medicine).

Thankfully, the child didn't ingest any glass. But that's not why I'm writing about this incident. The reason I am writing about this is because the mother has delayed vaccination for her child, something that is unequivocally not safe. 

I find it hard to fathom that while a glass ingestion is correctly thought of as a clear and present danger to her child, vaccine-preventable illnesses--which kill incalculably more children than glass ingestions ever could--doesn't register the same sense of alarm in this mother.

The only explanation I can come up with is a serious threat misperception akin to fearing shark attacks but not drowning in the neighborhood pool--something that has to do with what is known as an availability heuristic coupled with the ability to imagine a horrible outcome. In this example, it is not hard for a mother to imagine her child ingesting glass and having a horrible outcome while it may be harder for her to imagine her child contracting a disease made rare because of the success of vaccines. 

This explanation carries some weight as we see the availability heuristic working for the vaccine cause after the Disneyland measles outbreak made it much easier for parents to imagine their child contracting measles and thus the increased support for vaccines.

I wish this mother realized that vaccines--as well as a broken glass free environment--are a crucial measure needed to keep her child safe .

A New Arrow in the Pro-vaccine Quiver: Eula Biss's On Immunity

I'm often accused of not seeing the other side of the vaccine "debate". I think that's a fair description of me, but it's for a good reason--there is no other side. However, it is understandable that a lay person inundated with multiple layers of misinformation may be honestly mistaken and fall prey to the anti-vaccine movement. Once in the clutches of the movement, it can be hard to reach such people. For example, the standard vaccine books often do not make any headway against what is, for many, a largely emotional conclusion against the power of vaccines. As such, many physicians feel resigned to accept that some people are unable to be swayed. However, there is a new tool available.

Eula Biss's On Immunity: An Inoculation is a remarkable book that I believe will fill an important niche in the defense of vaccines and has the potential of persuading those who doubt the benefit of vaccines to re-examine their conclusions. The book is a journey through the honest deliberations Ms. Biss herself undertook with the birth of her son. Rightly concerned with her newborn's safety and protecting him from harm (like the mother of Achilles--see the cover art), Ms. Biss's diligence to unpack arguments for and against vaccines is instructive as it shows how an active mind approaches complex issues and weighs the testimony and work of experts--an important trait that extends beyond vaccines.

 The comparative advantage and immense value of Ms. Biss's book is that it offers the reader a glimpse of how a non-medical individual approaches the issue of vaccination, what context of knowledge is activated, and how risk is assessed. In all of these realms, Ms. Biss excels and provides ample data (as well as expertly chosen anecdotes) to concretize the important points she makes throughout. 

Doing battle with those who would return us to the primitive with their opposition to vaccines--an unmitigated triumph of technology--will be a little easier with Ms. Biss at our side. I highly recommend her book.

Measles in a More Rational Bygone Era

For those who brush off a disease such as measles, that hospitalizes 1 in 4, as no big deal because it was a routine illness pre-vaccine I recommend watching a specific episode of the 3rd season television series Lark Rise to Candleford, which aired on the BBC from 2008-2011. 

This series catalogs the daily comings and goings of two towns in turn-of-the-century England, one of which is rural. Stories center on various aspects of daily life and are thoroughly interesting. One episode I recently watched brought up the issue of what measles could mean to a rural community in that era and it was devastating. 

Cases begin within a trickle and then an onslaught, reflecting the sheer power of this contagion to infect a naive population. Many townsfolk recounted prior bouts of measles which made children "fodder for the epidemics" and thinned families as not every case is uncomplicated. One character, who runs a post office out of her home and is caring for a sick child in the household, astutely moves activities to an alternate site. She matter of factly states she would not have the post office, which is the social focal point of the town, be exploited by the virus as a source of new victims.

One point which is heavily emphasized is the burden sick children place on caregivers as this incident occurs during harvest season when all hands must be on deck in order to have food for the winter. While this is an obvious issue in an agrarian population in the late 1800s, it is still a very instrumental fact today as is evident when a child gets sick and often requires a parent to take time away from productive endeavors until the child convalesces. The caregivers of children with influenza, for example, miss an average of 73 work hours.  

In the 4 current US measles outbreaks that have occurred thus far this year, there is no doubt that each of the children afflicted rightly requires special care from their parents--hospitalized or not--and such a requirement has ripple effects. This phenomenon, often overlooked, is another example of the life-enhancing aspect of vaccines as they not only diminish the burden of disease but minimize the impact on those who are not directly infected.

This crucial fact was grasped by the human race in a more rational era when vaccines against many childhood illnesses had not been developed and the toll of these scourges was a threat from which no one could escape.