A new epidemic is creeping across parts of the US. It primarily affects infants and children of higher socio-economic status, and it has the potential to cause horrible illness and death. It has already begun to cause outbreaks in scattered communities throughout the country. If it is not contained quickly, more carnage will result. The epidemic I am describing is not Swine Flu. It is not a newly mutated animal virus imported from some far-flung corner of the globe. It is the epidemic of parental vaccine fear, and it is a major threat to the safety of children everywhere.
As a pediatrician living in New York, I often see soon-to-be parents who are expecting their first child and are looking for a doctor for their new baby. These prenatal visits are usually a time for parents to ask some basic questions about my practice, maybe a few questions about what to expect in the first days after the birth of their child, and mostly to get a feel for me and my office. But an interesting change has occurred over the last few years. A new item has cropped up in the usual list of new parent questions: vaccines. A common question I get is “what’s your philosophy about vaccines?” My response to this question is something along the lines of, “well, it’s not a matter of philosophy. It’s actually a matter of science, and I follow what the science tells us.” In fact, I can’t remember the last prenatal visit that didn’t include at least one question about vaccines. What in the past was a given – that children would receive the vaccines recommended by their pediatrician, in the order that they were recommended – is no longer so for many parents today . This bedrock of pediatric care has been recast as a question, an uncertainty, a matter of opinion and debate. It is a dangerous new dynamic that seriously threatens the safety of our children. Many parents have vague concerns about unspecified risks, but in general need only reassurance to go forward with vaccinating their children. Some parents have specific concerns based on information gathered from friends, acquaintances, on the internet, or in the media. Some have fears about vaccines in general, or the number of vaccines given, and are less easily reassured. Some parents are ardently opposed to vaccines altogether, and refuse to have their children vaccinated at all.
What has led to this new epidemic of fear? The answer is complex, involving a convergence of multiple factors: a lack of understanding of how science works, mistrust in medicine in general and in expert advice even more generally, mistrust in government oversight and the pharmaceutical industry, and a growing counter-culture trend, particularly in more highly educated socio-economic populations. The most common vaccine concerns can be summarized as follows:
- Vaccines have been linked to autism – While this is true, vaccines have been linked to autism, they don’t actually have anything to do with autism. I will not tackle this myth here, but suffice it to say, not a single shred of valid scientific evidence has ever been put forth to support a causal link between vaccines and autism. However, volume upon volume of excellent, peer-reviewed data has unequivocally shown no such a linkage [for a complete set of references, see the references section of this post from the Science-Based Medicine blog].
- Vaccine ingredients, like thimerosal, aluminum, squalene, and others can lead to immunological and neurological consequences in infants – Again, no valid data exists to support such a belief, and the existing science points us in the opposite direction.
- Too many vaccines can overwhelm an infant’s immune system, leading to a host of disease conditions – This is absurd on its face to anyone familiar with basic immunological principles. All of the childhood vaccines combined, are but a mere drop in the bucket compared to the immunological challenges an infant faces every day. Not only can an infant’s immune system easily handle the combinations recommended in the routine schedule, but the number of immunologic stressors, if you will, contained in the current schedule (that enormous, and growing list the anti-vaccine community complains so much about) has actually been decreasing due to improved vaccine technologies .
As I mentioned above, the reasons for this spreading wave of mistrust of what was once regarded as the greatest weapon against childhood disease, are complex. But a single, now thoroughly discredited paper published over 10 years ago, purporting to show a linkage between the MMR vaccine and autism, is responsible for at least this current, modern wave of anti-vaccinationism. So much has been written about this paper and the damaging fallout resulting from its publication, that I wont rehash it here . But the subsequent media frenzy, and numerous tangential theories, equally unsupported by science, has kept the frenzy alive .
My pediatric practice is situated at the nexus of three Manhattan neighborhoods (the West Village, Chelsea, and the Meat Packing District) that seem to comprise just the right balance of wealth, edginess, and socio-cultural awareness that lends itself to this new mistrust of vaccines. But these neighborhoods are not unique. According to sources at the NYC DOH, the Upper West Side of Manhattan and Park Slope in Brooklyn are also hot-spots of parental vaccine resistance. What stands out about these neighborhoods, and others like them, is that they contain a high percentage of middle to upper middle class families that tend to be young, well educated, and liberal in their political and social views. Because I live in one of these areas, work in another, and fit this description pretty squarely, I can identify with the underlying tendencies at work behind the concerns of these parents. A healthy questioning of authority (doctors), an underlying mistrust in the competence of the government (the CDC), overt mistrust and a general level of cynicism of big business (the pharmaceutical industry), and a sense of empowerment that comes with one’s social status, all contribute to this tendency to mistrust vaccines and those who recommend them. The difference between these concerned parents and myself (also a parent), is an understanding of the scientific method and the role it plays in this issue. One term that I have purposefully left out as a key element in this new epidemic is “skepticism.” While many of these parents believe they are being skeptical of vaccines, their manufacturers and the agencies that recommend them, this couldn’t be further from the truth. What they are being is misled and taken advantage of. They would actually be better characterized as anti-skeptics. To quote Brian Dunning of Skeptoid.com,
The true meaning of the word skepticism has nothing to do with doubt, disbelief, or negativity. Skepticism is the process of applying reason and critical thinking to determine validity. It’s the process of finding a supported conclusion, not the justification of a preconceived conclusion.
The net result of this snowballing paranoia and anti-skepticism, is that the door has opened wide for anti-vaccine fear-mongering by an increasing number of organizations and non science-based “maverick” doctors, and parents are listening. Not a day goes by in my practice without encountering the effects of this mass-hysteria. Parents are afraid of vaccines, victims of a cultural mythology about vaccine risks that has been bolstered by a wave of media hype and irresponsible pseudo-journalism. I spend a large amount of time with parents discussing the real science and trying to debunk these hardened myths. Often I am successful at convincing them to vaccinate their children. Many, while agreeing to all or most of the vaccines, ask to use a “spread-out” or “alternative” schedule, like the one recommended by Dr. Bob Sears (see my take-down of him on the Science Based Medicine blog). While not every parent is familiar with Dr. Sears, most are aware that there is an “alternative” to the schedule recommended by the CDC Advisory Committee on Immunization Practices and the American Academy of Pediatrics. Forget that an enormous amount of thought and deliberation went into devising this schedule by our nation’s leading experts in pediatric infectious disease, epidemiology, and vaccinology. Parents now know there’s an “alternative,” and for some that’s good enough. Many who choose the “alternative” schedule can’t really give a reason why, other than “I’ve heard it’s safer.” This is no different for the vast majority of parents who have concerns in general about vaccines; they know they’re worried about vaccine risks, they just don’t know exactly why. Amazingly, this lack of a basis for their concerns doesn’t prevent these fears from taking control and informing what is likely the most important decision they will ever make about their children’s health. Fears about non-existent vaccine risks prevent children from being protected against very real, very dangerous agents of death and disease.
A trendy way to die
So why are parents so quick to make such bad decisions for their children when it comes to this issue? And why does there seem to be a connection between zip code and vaccination rates? Unlike most of the world, where vaccination rates are directly proportionate to socioeconomic status, it appears that may not always be the case here in NYC, and probably other urban centers around the country. Typically, under-vaccination has been found to be most prevalent in inner city, black children with unwed teenage mothers, while un-vaccinated children have tended to come from higher socioeconomic backgrounds, and have mothers who are married with a college degree . The reasons for this are that under-vaccination has typically been a result of poor access to good health care continuity for children at or below the poverty level. Non-vaccination is usually a result of a decision made by a parent who has major concerns about vaccine safety, and who is empowered to reject the expert advice of authority. Such strong, anti-vaccine positions were once confined to a very small subset of the population. Complete vaccine refusal remains, fortunately, a relatively rare occurrence in the US. But under-vaccination is being seen increasingly now in communities where being up-to-date with vaccinations was a once given and, in fact, a marker of the highly educated and socially aware. Now, as more and more socio-economically advantaged, empowered, parents play with the vaccine schedule, cherry-picking which vaccines to give and when, the problem of childhood under-vaccination may be changing from being predominantly a result of inner-city poverty, to that of cultural elitism. In other words, we are experience a very dangerous fad, where it is now trendy to question the advice of one’s doctor, and to mistrust medical experts in general. Of course children are the ultimate victims.
The growing trend of questioning the safety of vaccines, and even the very concept of vaccination itself, has resulted in pockets of underimmunization throughout the country. The increasing number of such hot-zones has already resulted in outbreaks of completely preventable childhood disease.
Soon after the infamous Wakefield paper was published in 1998, vaccination rates against measles, mumps, and rubella, plummeted in the U.K. Outbreaks of these diseases began popping up all over the region, eventually reaching epidemic proportions. And, although the fictional link between the MMR and autism arose over 10 years ago, there’s no sign that things are getting any better. Last year saw the highest incidence of measles cases in the UK in over 20 years, all due to pockets of underimmunization resulting from media coverage of Wakefield’s discredited findings. Predictably, it wasn’t long before the wave of fear reached our shores. Although not as widespread, this uprising against vaccines, based on nothing but pseudo-science and newly spawned campaigns of misinformation, began to create a dangerous climate of vaccine refusal here in the U.S. It didn’t take long for outbreaks of mumps and measles to occur in areas scattered throughout the country. In 2006, the largest outbreak of mumps in over 15 years, centered in Iowa and involving 10 other states, effected over 2,500 people. Last year, measles cases in 15 states contributed to the largest US outbreak in over 10 years. In Brooklyn, an unimmunized traveler from Israel infected other unimmunized children in a pediatrician’s office, sparking the borough’s largest outbreak of measles in almost 20 years. Other recent outbreaks in Indiana, San Diego, Arizona, Milwaukee, Washington State, Pennsylvania, Michigan, and Texas are just the tip of the iceberg if this dangerous trend of vaccine refusal continues.
Much to the horror of pediatricians, recent outbreaks of invasive disease due to Haemophilus influenzae type b (Hib) have brought back this dreaded scourge. Hib is an extremely nasty bacterium that used to cause invasive disease in a startling 1 of every 200 children in the U.S. under 5 years of age. That was, until the vaccine pretty much eliminated it from our country after its introduction in the late 1980s. The vaccine has been so successful, that pediatricians my age and younger have likely never even seen a case of invasive Hib disease. Not true for those trained just a few years earlier. They remember that, of the children unfortunate enough to come down with invasive Hib disease, approximately two-thirds will develop meningitis, and about 5% will die. Up to 30% of the survivors suffer permanent brain damage. Those children lucky enough to avoid meningitis develop pneumonia, septic arthritis, osteomyelitis, cellulitis, epiglottitis, or generalized sepsis. Now, because of pockets of underimmunization and the spread of so-called “alternative” vaccine schedules, younger pediatricians will be able to learn, first-hand, about a disease they could previously only read about in text books.
Pertussis, or whooping cough, is one vaccine preventable disease that still circulates with high prevalence despite the existence of a good vaccine. In fact, the incidence of pertussis is actually increasing in the U.S. There are several reasons for this, including inadequate vaccination of infants, waning of vaccine-induced immunity in adolescents and adults, and a high frequency of undiagnosed pertussis infection that can lead to spread of disease to susceptible individuals. Another reason is that, although an adolescent/adult version of the vaccine (Tdap) is now recommended and routinely given to children 11 years of age and older to boost their immunity, similar recommendations to vaccinate all adults are usually unheeded by internists and obstetricians. This is a major problem, because infants and children (in whom pertussis can be an extremely severe disease) are infected by adults whose immunity to pertussis has waned. Anecdotally, I can tell you that most of the physicians I’ve spoken to who take care of adults, are not even aware of these recommendations (I’m currently working on a study of knowledge and attitudes of obstetricians about the Tdap vaccine.) Now, add to this the changing attitude of parents concerning vaccines, and we have a dangerous set-up for an even worse scenario with regard to the future of pertussis control in this country. Not surprisingly, it has been shown that when parents refuse or delay the pertussis vaccine for their children, these children have a significantly higher risk of developing pertussis . The danger of an increasing incidence of pertussis is that, while it is an extremely annoying disease for adults, it’s an extremely dangerous one for infants and young children, in whom complications are much more common and include pneumonia, dehydration, encephalopathy, cerebral hemorrhage, and death.
The Pendulum Swings
An often-used saying by those who fight against the irrationality of anti-vaccinationism, is that “vaccines are the victim of their own success.” Certainly, vaccination has been one of the most successful public health measures. They have been so successful, that most parents (and most physicians) have no first-hand knowledge of the diseases against which children are vaccinated. These horrific diseases are but an abstraction, and the ubiquitous nature of the myths about vaccine dangers – in the mainstream media, spouted by celebrities on TV, and on the internet – have become much more “real” to an increasing number of parents. Now, it seems, that the worst of our fears may be coming true. Not that vaccines cause autism, or multiple sclerosis, or asthma, or cancer, but that the parents who fall prey to these beliefs are leading us down a very dangerous path – a path we’ve been down before, and upon which we should never again have to tread. The pendulum has swung, and it may just be too late.
 Omer S, Salmon D et al. Vaccine Refusal, Mandatory Immunization, and the Risks of Vaccine-Preventable Diseases. NEJM 2009 360:1981-1988.
 Offit P., Quares J., et al. Addressing Parent’s Concerns: Do Multiple Vaccine Overwhelm or Weaken the Infant’s Immune System? PEDIATRICS Vol. 109 No. 1 January 2002, pp. 124-129
 Smith P. Chu S. et al. Children Who Have Received No Vaccines: Who Are They and Where Do They Live? PEDIATRICS Vol. 114 No. 1 July 2004, pp. 187-195
 Glanz J., McClure D. Parental Refusal of Pertussis Vaccination Is Associated With an Increased Risk of Pertussis Infection in Children. PEDIATRICS Vol. 123 No. 6 June 2009, pp. 1446-1451