Vaccines

3. A Brief History of Childhood Vaccines and Some Advice From a Pediatrician

Vaccines have become the best kept secret for saving lives in pediatrics. For better or worse, twenty-first century Americans tend to underappreciate vaccines because they haven’t personally experienced the devastation caused by vaccine-preventable illnesses. The impact of vaccines on our society cannot be overstated. A quintessential public safety measure, vaccines have saved countless lives and improved quality of life for humans in this country and around the world for more than two hundred years. Herein lies the crux of the problem. Because we’re no longer surrounded by vaccine-preventable diseases, the importance of vaccines is easily underestimated by modern Americans.

A historical timeline of vaccine-preventable illnesses helps to illuminate the impact of vaccines on society. Before Edward Jenner developed the first smallpox vaccine in 1796, about 50,000 people in the US developed smallpox yearly, and around 1500 died. Thanks to the vaccine, the disease was eradicated worldwide in 1977.

Prior to 1955, more than 16,000 people developed polio yearly in the US, and nearly 2000 died. Of the people who didn’t die, about 1/25 developed meningitis, and 1/200 suffered from paralysis, in some cases permanently. Incidentally, my mother contracted polio and developed paralysis of her right arm as an infant in 1949, six years before Jonas Salk developed the first polio vaccine (Salk also developed the first flu vaccine in 1938). The last case of wild polio in the US was diagnosed in 1979.

My grandmother, who came to America an immigrant in 1917, lost her little brother to measles during their transatlantic voyage. Prior to the 1963 licensing of the vaccine, more than three million Americans suffered from measles each year, nearly 50,000 people were hospitalized, 4000 developed encephalitis, and more than 400 died. Currently, in areas with low vaccination rates, the disease is still very much alive. In 2014 there were about 267,00 cases of measles worldwide and 146,000 deaths, mostly in children. In 2016, due mainly to mass vaccination campaigns, the global disease rate dropped to 90,000. This decrease represents an impressive 84% drop over 16 years.

In the early 1990’s, a major measles outbreak occurred in cities across the US (including LA, San Diego, Dallas, and NYC), resulting in close to 30,000 total cases—the highest number in the recent history of our country. The disease spread quickly amongst under-vaccinated preschool-aged minority children. More than 6000 people suffered complications from measles, such as pneumonia, encephalitis, and death.

On a personal note, one of my oldest friends was affected by the NY epidemic. We both graduated from high school in 1990, and she was living in Poughkeepsie, NY at the time. Although the local DPH recommended revaccinating children in the area for better protection against measles, my friend was getting ready to attend her senior prom, and she worried the shot would leave an unattractive mark on her arm (she was planning to wear a strapless dress and wanted to look her best). Sure enough, someone at the prom had the measles, and she came down with symptoms of the disease several days later. Ironically, her parents, who were both doctors, didn’t think she could possibly have measles, so initially they didn’t seek medical care. Several days later, my friend was hospitalized in a hospital ICU with delirium and encephalitis. She nearly died from an illness that was completely preventable.

Almost all cases of measles in the US today are imported from other countries. Unfortunately, the disease continues to proliferate in areas with low vaccination rates. In December 2014-January 2015, a measles outbreak infected 125 people in California, resulting in at least 17 known hospitalizations. The “Disney Land outbreak” was imported by an international visitor and perpetuated by low vaccination rates amongst locals. Forty-nine cases were unvaccinated, 28 by parental choice, not because the children were too young to receive the vaccine. Similar outbreaks have occurred within other poorly vaccinated communities. In 2014, 383 people in an Amish community in Ohio developed measles following an international exposure. Most of the patients (89%) were unvaccinated. These outbreaks illustrate that measles remains a prevalent threat outside the US, and that under-vaccination in this country makes some American communities vulnerable to widespread infection. For this reason and many others, parents should remain vigilant about vaccinating children against measles and other preventable infectious illnesses. Worldwide, the CDC estimates that for children born between 1994-2013, the measles vaccine will prevent 322 million illnesses, 21 million hospitalizations, and 732,000 deaths; roughly, the vaccine will have saved $295 billion in direct medical costs, plus another $1.38 trillion in societal costs.

Several years before the rubella vaccine was licensed in 1969, an outbreak affecting 12.5 million people occurred in America. Approximately 20,000 babies were born with congenital rubella syndrome—11,000 were deaf, 3500 were blind, and 1800 had intellectual deficits. This outbreak caused more than 11,000 miscarriages and resulted in over 2000 deaths. Since 2012, only 15 cases of rubella have been reported in this country.

In the early 1980’s, hemophilus influenza was the leading cause of bacterial meningitis and post-natal brain damage in children, with about 20,000 total infections occurring yearly. In 1998, 13 years after the vaccine was licensed, 125 total cases were reported in the US. The bacterium once caused thousands of cases of life-threatening epiglottitis in children, but this disease entity has essentially been eliminated.

Hardly anyone thinks of varicella, otherwise known as chicken pox, as a devastating illness. But in the early 1990’s, on a yearly basis in America, the virus infected four million people, caused more than 10,000 hospitalizations, and resulted in 100-150 deaths. Over the past 15 years in my pediatric office, I have encountered exactly ONE case of chicken pox. This child developed a severe secondary bacterial infection requiring antibiotics.

On a yearly basis, prior to licensing of the pneumococcal conjugate vaccine in 2000, streptococcus pneumoniae caused 13,000 cases of bacteremia in children, 700 cases of meningitis, five million ear infections, and 200 deaths in America. Worldwide, pneumococcus was responsible for about 14.5 million serious infections per year and more than 800,000 deaths, particularly in children and the elderly. Although disease rates have plummeted following widespread use of several vaccines, it is important to recognize that pneumococcus remains a significant threat at home and abroad. Strep pneumo is currently responsible for about four million illnesses yearly, nearly 500,000 hospitalizations, and 22,000 deaths, especially in children and the elderly.

Several years ago in my office I saw an almost two-month-old baby with fever who was two days shy of his first vaccine visit. This child turned out to have pneumococcal meningitis, a potentially fatal disease. Although he was treated promptly with antibiotics in the hospital, he later developed deafness in both ears, a common complication of meningitis. Aside from the hepatitis B vaccine, which is given in the hospital, the first set of vaccinations is currently administered at two months of age, a time in life when the immune system is particularly vulnerable to severe infections like meningitis. New parents often ask my opinion on whether vaccines should be delayed. My answer to them is always a resounding, “No! Of course not!” Vaccines should be administered on time, NOT according to alternative schedules. Young infants are at risk for significant infections with life-altering complications. Delaying vaccines in this age group (or any other age group, for that matter) opens the door for unwanted consequences. The baby who had meningitis, and his family, will be dealing with problems related to deafness for the rest of his life. Reflecting on this case, I often wish that the pneumococcal vaccine was licensed for administration immediately after birth. Indeed, one study demonstrated, “…doses [of pneumococcal vaccine] given at birth have been shown in a clinical trial to be immunogenic and prime for doses given later.”

In the early 1920’s, pertussis, or whooping cough, infected more than 200,000 people per year. Then and now, young infants are particularly vulnerable to the disease and have the highest mortality rates. In 2016, seven children died from pertussis in the US, and six of these patients were under one year of age. Like pneumococcus and influenza, pertussis is an example of an infection that actively circulates across our country and internationally. In 2012, the most recent peak year in the US, 50,000 cases of pertussis were reported (the numbers are probably much higher, as many cases go undiagnosed and unreported). Immunity to the pertussis vaccine unfortunately wanes over time, which helps to explain why the disease is still so prevalent. Because infants cannot receive the pertussis vaccine until two months of age, it is essential that pregnant women get the Tdap vaccine, which protects against pertussis, tetanus and diphtheria. During pregnancy, maternal antibodies are passed to the baby through the placenta, and following delivery antibodies are transferred to the baby through breast milk, if the baby is nursing.

Because influenza (“the flu”) is not a reportable illness, the data listed below are an estimation. From 2015-2016, flu caused about 9-35 million illnesses in the US, 140,000-710,000 hospitalizations, and 12,000-56,000 deaths. While vaccine efficacy is unpredictable, because the virus frequently mutates, the CDC estimates that flu vaccine prevents five million illnesses yearly, along with 2.5 million healthcare-related visits, 71,000 hospitalizations, and 3000 deaths in this country.

Years ago, when I was younger and dumber, I didn’t push families particularly hard to get the flu vaccine. Then a patient taught me a lesson. A previously healthy teenage boy with no medical history walked into my office one winter evening with a cough and a 105 fever. A rapid flu test quickly confirmed he had the flu, but something wasn’t right. A blotchy pink rash had appeared on his back, and his lung exam had a few crackles. Reassuringly, his blood pressure and oxygen level were completely normal. I asked the patient whether he would prefer to go home, or head to the emergency room for a CXR to rule out pneumonia. The patient’s response was, “I want to go to the hospital.” When a sick person says that I never argue. So off to the hospital went the patient and his mother. Several hours later I received the terrible news that this patient was fighting for his life in the intensive care unit. Soon after his arrival at the hospital, he had gone into septic shock from a secondary bacterial infection (pneumonia caused by staph aureus, a common complication of the flu) and was requiring intravenous fluids and pressors to maintain his blood pressure. And I nearly sent this patient home from my office! I am convinced that had he gone home, he would’ve died that night in his bed. Thanks to divine providence, a smart mother, and excellent medical care in the ICU, my patient ultimately survived the illness. These days, when someone asks me whether healthy people really need a flu vaccine, I always answer, “Yes!”

Incidentally, this case isn’t unlike the ones we’re all hearing about in the news media right now, during the 2017-2018 flu season. Although this year’s flu vaccine hasn’t been a great match for circulating strains of the virus, studies are showing that people who contract the more virulent H3N2 variety will have a milder course if they previously received a flu vaccine.

One of the biggest killers of 21st century Americans is cancer. Given the heavy cancer burden in this country and all the misery it causes patients and their families, you would think most people would be quick to embrace an anti-cancer vaccine. Yet this hasn’t been the case. The vaccine to which I’m referring is Gardasil. Though Gardasil was originally licensed for cervical cancer prevention in 2006 (12 years ago as of 2018), and the data supporting its use is now very strong, the vaccine is still  being refused by about 40% of families. Even before they reach my office, many parents have already made up their minds about not wanting Gardasil, and there may be nothing I can say to change that opinion.

Like many other pediatricians, I find this frustrating, mainly because Gardasil is turning out to be an incredibly important preventive public health measure for saving lives. Gardasil prevents Human Papilloma Virus, or HPV. HPV is a sexually transmitted illness that is responsible for causing a multitude of cancers, including cancer of the cervix, vagina, vulva, penis, anus, rectum, and oropharynx. Wherever the virus can live, it can cause cancer. HPV has been referred to as a “hidden epidemic,” which is an accurate description. According to the CDC, about 80-90% of American women and men, respectively, will at some point be infected with HPV. Half of these individuals will acquire high-risk strains capable of causing recurrent disfiguring warts (either in the genitalia or oropharynx) or cancer. Initially, HPV is a silent infection. Not unlike an initial infection with HIV, most people don’t realize they’ve contracted the virus. Importantly, intercourse is NOT required for transmission. Skin-to-skin physical contact and oral sex can easily spread the virus, which has contributed to its ubiquity.

In total, HPV is directly responsible for nearly 32,000 cases of cancer each year in the US, plus an even larger number of precancerous conditions requiring invasive treatment. Although there are many strains of HPV (about 40 are sexually transmitted, and 60 cause common warts), a small subset is responsible for causing genital warts and cancer. Specifically, nine aggressive strains (6, 11, 16, 18, 31, 33, 45, 52, and 58) are targeted by Gardasil. The vaccine is potentially capable of preventing more than 90% of cervical and anal cancer, along with high percentages of the other cancers mentioned above. It is important to recognize that the vaccine must be administered PRIOR to exposure, before a person is sexually active. Once a person becomes infected with a cancer-causing strain of HPV, the vaccine can no longer protect against that strain.

In the US, Gardasil is covered by insurance from 9-26 years of age. In my practice, I usually offer it to patients at age 12, mainly because children aren’t due for other vaccines at this time, and I like to keep visits as pleasant as possible. Because the immune response is so robust for young teens, they only need two shots to achieve 100% immunity. People over age 16, however, need three vaccines.

On a positive note, recent data from Australia indicate that the HPV vaccine is already having a significant impact on disease rates. The rate of JORPP (juvenile-onset recurrent respiratory papillomatosis), an incurable and potentially fatal respiratory illness in children caused by mother-to-child HPV transmission at birth, is declining for the first time ever. The Australia surveillance program detected a decline in incidence from .16 to .02 cases per 100,000 people from 2012 to 2016, the time frame corresponding to widespread vaccination with HPV. This improvement is only the beginning of the positive change we’ll see as vaccination against HPV becomes more routine. Interestingly, in Australia the vaccine is covered for people up to age 45. In my opinion, if an older adult is sexually active and not immune to HPV, then getting the vaccine is an excellent idea. Out of pocket, one Gardasil shot costs about $150, and three shots are required to vaccinate people who start the series later. Though it isn’t cheap, the cost of receiving three Gardasil vaccines is far less than the cost of treating cancer.

Which brings us back to the puzzling question, why do so many parents regularly reject Gardasil in pediatric practices across the country?

From the time that vaccines were first developed, people have spoken out against them due to a combination of mistrust, misunderstanding, and disbelief. The Anti-Vaccination League and the Anti-Compulsory Vaccination League, for example, arose in the mid-1800’s in response to laws making the smallpox vaccination compulsory. In general, new concepts and technologies are frequently rejected at their inception (climate change, anyone?). The practice of questioning scientific proclamations is robust in America, and this isn’t necessarily a bad thing. On the upside, our public education system seeks to build critical thinking skills. Instead of blindly accepting authority, we are taught to examine evidence and form our own opinions. But at some point, hard scientific data should lead to definitive conclusions. Yet people rationalize or reject such data when it conflicts with core tenets of their worldview. Furthermore, critical thinking can fall apart when inaccurate information enters the mix, muddying the waters, making it difficult or impossible to reach educated conclusions.

One of the muddiest moments for vaccines arrived in 1998, when Dr. Andrew Wakefield published a paper in The Lancet claiming that the MMR vaccine caused autism in children. Although Wakefield’s data was found to be fraudulent, and he was completely discredited, the paper caused lasting damage to the general public’s faith in vaccinations. If you’re a person who is feeling doubtful about vaccines and autism, I’m happy to report that a multitude of scientific studies have been completely reassuring. In 2012 the Cochrane Library published a review article including about 14,700,000 children which showed absolutely no link between vaccines and autism. Other large studies have reached the same conclusion, time and again.

If you’re still not convinced, then you’re probably spending too much time on the internet. On the web, anyone can say anything. Below I’ve listed some common untruths you might find there.

Falsehoods about Gardasil:

  1. Gardasil is part of a government conspiracy to sterilize our population.
  2. Gardasil causes paralysis.
  3. It isn’t safe to receive Gardasil.
  4. The Gardasil vaccine has killed people. False. No one has ever died from a Gardasil vaccine (see below).
  5. Giving Gardasil to your child will encourage her to have sex at an early age.

Falsehoods about vaccines in general:

  1. Vaccines weaken the immune system. Wrong. They strengthen the immune system by building up our supply of antibodies.
  2. The injectable flu vaccine causes influenza. False. The current flu vaccine is 100% inactivated. Yes, you might feel tired for a day or two following the vaccine, and your arm might be a bit sore, but you CANNOT get influenza from an injectable flu vaccine.
  3. Vaccines cause autism. Not true, see above.
  4. Vaccines are a conspiracy perpetrated by Big Pharma. Wrong again! Although pharmaceutical companies do make some money on vaccines, they represent a tiny portion of overall profits; moreover, immunization prevents diseases that would require treatment with other, far more expensive medications, were the diseases allowed to run their course. Gardasil, for instance, prevents a multitude of cancers that would necessitate treatment with expensive procedures and chemotherapy drugs. In general, preventing disease garners less money for Big Pharma than allowing illnesses to wreak havoc. A well-written article on Big Pharma and the flu vaccine was published in 2015, and the web address is listed below:

https://www.skepticalraptor.com/skepticalraptorblog.php/flu-vaccine-myth-big-pharma-profits/

  1. Alternative vaccine schedules are good for children because getting three or four vaccines at one time can overwhelm the immune system. A concise piece written by Dr. Mark Crislip and Dr. Stephen Barnett soundly refutes this faulty conclusion. A person’s immune system, they explain, has the capability of producing about 10 billion antibodies. In a lifetime, most people will make about 1-100 million antibodies. Collectively, the childhood vaccines induce production of a mere 30 antibodies. Theoretically, we would have to get 10,000 vaccines at one time to reach our immunologic capacity. On a related point, I would never recommend delaying vaccines or using alternative schedules for young infants. Younger infants, especially those under the age of three months, are particularly vulnerable to life-threatening infections, like meningitis.
  2. You can trust the anti-vaccine information on Dr. Joseph Mercola’s web site. FALSE, with a capital F. Websites like Mercola’s are dangerous because the information presented seems scientific and well reasoned, yet isn’t based on scientific facts. “Pseudoscience” websites like this one twist data with the intention of manipulating public opinion. Mercola’s website, for instance, states that Gardasil has caused more than 200 deaths. Despite the information listed here and on numerous other websites, Gardasil has not caused any deaths. Think of it this way: for people who are alive, the risk of death is 100%. Because some people die at a young age, a certain percentage of individuals vaccinated against HPV will die not long after they receive the vaccine (eventually, 100% of them will die). But this doesn’t mean Gardasil caused them to die. Mercola’s website is filled with similarly misleading information. If no one believed it, no problem; but some parents viewing websites like Mercola’s are going to decline Gardasil, unnecessarily putting their children at risk for cancer.
  3. The mercury preservative used in vaccines is dangerous. No, it’s not. Moreover, aside from multi-dose flu vaccine, childhood vaccinations no longer contain mercury. The last childhood vaccines containing mercury were phased out in 2003.
  4. The aluminum adjuvant in vaccines is dangerous. It causes Alzheimers disease and breast cancer. Wrong again, on all counts! Aluminum is a ubiquitous element that people ingest everyday through food and drinking water. Most of the aluminum we consume passes through the digestive tract without getting absorbed. Each day people swallow about 10-100 mg of Aluminum. Over a one-year period, the highest amount of aluminum a baby could receive through vaccines is about 4.2 mg, a miniscule and safe dose
  5. Getting measles is no big deal. If my child gets the measles, she’ll get great medical care at an American hospital. Nothing bad could possibly happen. Wrong! Even with great medical care, people infected with measles still have plenty of complications.

-1/20 develop pneumonia, the most common cause of death

-1/10 develop ear infections, which can cause permanent hearing loss

-1/4 require hospitalization

-1/1000 develop encephalitis (like my friend from Poughkeepsie, NY, who once refused a measles vaccine during a local outbreak); encephalitis can cause deafness and permanent neurologic disability

-1-2/1000 will die

  1. My parents didn’t vaccinate me, and I never got sick, so why should I vaccinate my kids?

You never got sick because everyone around you is vaccinated. In other words, you are being protected by “herd immunity.” Furthermore, you’re an N of 1. Just because you didn’t get sick doesn’t mean your children won’t.

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