One of the running ha-has at LeagueFest was the seeming predilection Rose and I have for hot-button topics. Between circumcision, attachment parenting and home birth, one could draw the conclusion that we like to go “poke, poke, poke” at the hornet’s nest of various emotionally-charged issues. I think I speak for both of us when I say that, while it’s always nice to get page views, it’s not necessarily the most fun thing ever to have a comment thread largely devoted to what a stupid, child- (or woman-)hating fascist you are. We don’t do it on purpose.
To that list of topics, you can now add vaccination. I haven’t written a basic post before about why I support vaccination for all healthy children, largely because “pediatrician supports vaccinations” seems the kind of obvious notion that doesn’t even need stating. Plus, one can reasonably expect that posting on the topic will invite yet another deluge of “why do you want to poison our children?” comments, and who really has that kind of time? However, when a regular commenter makes a request, who am I to refuse?
Over at the main page, Miss Mary asks:
I’ve heard you mention that you are fond vaccinating children a few times. Did you ever do a post on why this is so important to you? I’m just interested in hearing more.
I wouldn’t say I’m “fond” of vaccinating children. Jabbing children with sharp things (I give my own shots) is no fun. But I absolutely, without equivocation support full vaccination for all* children on the recommended schedule.
I support routine vaccination because vaccines save lives. There are few things modern medicine has accomplished that are such an unalloyed good as immunization. (A few other things in that category that spring to mind are insulin, chemotherapy for most cancers, effective antisepsis, anesthesia for surgery and antibiotics.) Routine vaccination has led to the near-eradication of numerous diseases that used to kill thousands of children in the United States, to say nothing of the rest of the world.
Attributing the decline in the incidence of these diseases to advances in hygiene, sanitation and nutrition alone (as is a common trope of anti-vaccine crusaders) strains credulity. Yes, these things certainly help, but vaccinations deserve the lion’s share of the credit. To demonstrate this point, let’s look at three totally different vaccine-preventable infectious diseases, the immunizations for which were introduced at different times — tetanus, hepatitis B and haemophilus influenzae type B (HiB).
Tetanus is caused by spore-forming bacteria found in the soil. It cannot be eradicated, short of massively irradiating the earth’s crust. In order to cause disease, it has to gain entry into a person’s body through direct insertion into a deep wound; it is not spread person-to-person. Hepatitis B is a blood-borne viral infection of the liver, which is spread through contact with infected blood (eg. through IV drug use), through sexual contact or from mother to infant. HiB is a bacterial infection that is transmitted when carriers (who carry the pathogen in their respiratory tracts, and are quite often symptom-free themselves) pass it through droplets (eg. sneezing). All very different reservoirs and clinical illnesses, with very different mechanisms of infection.
Before routine vaccination, tetanus sickened 500-600 people per year [PDF], killing about a third of them (horribly). Since the introduction of the tetanus toxoid vaccine in the 1940s, the incidence rate has fallen precipitously. In 2009, there were 19 reported cases in the United States [sorry, another PDF]. While some of this decline can be attributed to improved wound hygiene, the most significant factor was the advent of vaccination. Of those who contracted tetanus from 1972 through 2009, the overwhelming majority (84%) were un- or under-vaccinated.
Because the route of transmission for all children infected with hepatitis B is from an infected mother (with ~90% of them going on the chronic infection), routine vaccination for all newborns was begun in 1991. From 1990 through 2004, there was 94% decline in the incidence of hepatitis B in children and adolescents, coincident with a 92% coverage rate with the vaccine. While much of this success is also attributable to screening pregnant women for hepatitis B, screening is worthless unless it is coupled with targeted neonatal vaccination. Attributing the decline in childhood infection to any intervention other than vaccination is highly implausible.
HiB infections manifest in a variety of illnesses, including (among others) meningitis, septicemia and epiglottitis (a severe and life-threatening swelling of the upper airway). Prior to the introduction of a vaccine in 1985, HiB was the most common cause of invasive bacterial meningitis in children, accounting for roughly 20,000 cases per year (with about a 5% mortality rate, and about 20% of survivors suffering permanent hearing loss or other disability). There has been a 99% decrease in HiB disease since vaccination against it became routine, with less than one case per 100,000 people. There is no other significant change in public health in that time period that can be credibly linked to this decline.
To these three, you can add many other diseases, including (but not limited to) polio, diphtheria, measles and meningococcal meningitis. Vaccines save lives. It is an act of willful blindness to aver otherwise.
I am aware of the concern about autism. I am even aware of the occasional study that seems to lend credence to the concern that there is a link between autism and vaccination. (They largely seem the work of a particular couple of authors.) The vaccine-autism link was first introduced by a man who has since been exposed as a fraud, and his landmark study retracted by the journal that published it. The link has been attributed to thimerosal, a preservative used in some vaccines, and also to the MMR vaccine itself. Both of these associations have been thoroughly investigated and debunked by several studies. The massive preponderance of evidence does not support a causal relationship between vaccines and autism. [I apologize that a few of those links are only to abstracts. I cannot find non-subscription, full-text versions.]
Further, for there to be such a strong link between vaccines and autism as anti-vaccine advocates claim, it would require an amazing degree of malicious indifference on the part of my fellow pediatricians to keep giving them. From residency until now, I have taken care of thousands of patients and worked with dozens of experienced physicians. I have neither seen or had reported to me by any of my colleagues (including many who have been in practice for decades) a single case of autism that could be attributed to vaccines. To what motivation would those who oppose vaccination attribute pediatricians’ persistent devotion to immunizing our patients except that we firmly believe it benefits them? Do they think we are all in thrall to Merck? If you think vaccinating children is a huge cash cow for medical practices, allow me to disabuse you of that notion. We ain’t getting rich from administering DTaPs. I realize this is just me talking here, but I promise you that if we truly saw that vaccines were harming our patients we would stop administering vaccines! We went into pediatrics in the first place because we want to help children, not because of some sinister allegiance to Sanofi.
Vaccines make the world safer. They prevent horrible disease that kill or disable. They allow us more freedom, in that we can freely assemble with less fear of contagion. (To be fair, modern hygiene and sanitation really do help with that, too.) We can more confidently send our children to be educated in schools because we don’t have to fear they will be slowly strangled to death by diphtheria or crippled by polio. Even for diseases that are merely intensely unpleasant but rarely fatal in the United States (like chicken pox or rotavirus), we are a more prosperous nation because parents need not lose a week of productivity caring for their convalescing children. What more good could one possibly ask of a simple, low-risk medical intervention than this?
But people still refuse. They believe the fear-mongers and the charlatans. Of course, no vaccine is 100% effective, and so to truly keep our population safe immunizations must be given to a sufficient number of people to provide good herd immunity. Once a certain threshold of coverage is missed, previously-controlled illnesses resurface. Over and over and over. For no good reason whatsoever.
Vaccinating your children is, without question, the responsible thing to do. It’s the right thing for them, and it’s the right thing for your community. Relying on the good decisions of other parents to provide herd immunity to protect your children is asking others to shoulder a risk you refuse to accept for yourself. (Never mind that the risk is incredibly low in reality.) It is bad citizenship, as well as irresponsible parenting. My kid is fully vaccinated, and everyone else’s should be, too.
* The above post pertains to children who do not have an obvious contraindication to vaccination. Children who have certain immune deficiencies should not receive certain vaccines. Children who are allergic to certain vaccines or vaccine components should not receive those vaccines. And there is one plausible case that a child with a rare mitochondrial disorder may have developed encephalitis after having received several vaccines, though that is far from a settled question. For the vast majority of children, vaccines are perfectly safe.