THE FORTNIGHTLY CLUB
Of
REDLANDS, CALIFORNIA
Founded 24 January 1895
Meeting Number 1840
4:00 P.M.
March 14, 2013
VACCINES AND THE ANTIVACCINATIONISTS
Boyd A. Nies, M. D.
Assembly Room, A. K. Smiley Public Library
Summary
Vaccines have saved more lives that any other medical intervention. Despite this record of success, anti-vaccine groups have been present since the time of the first vaccine. Factors important in the origin of anti-vaccine movements include lack of memory of the devastation caused by the disease which the vaccine subsequently controlled, the distrust of those promoting the vaccinations, the assumption that vaccine causes medical problems occurring after vaccination despite lack of evidence, ignoring or not understanding the concept of “herd”, immunity, and religious and philosophical objections. More recently, television, the internet, and social networking sites have provided opportunities for more rapid dissemination of inaccurate material. Anti-vaccine groups have weakened the requirement for vaccinations prior to school enrollment by making opting out of that requirement relatively simple. Suggested steps to increasing the vaccination rate include better communication, continuing scientific studies, and improvement in scientific literary education.
Background of the Author
Boyd A. Nies was born and raised in Orange, California. He graduated from Stanford University in 1956 and from the Stanford University School of Medicine in 1959. An internship and residency in Internal Medicine at the UCLA Medical Center and the Wadsworth Veterans Administration Hospital was followed by sub-specialty training in Medical Oncology at the National Cancer Institute in Bethesda, Maryland and Hematology at the Stanford University Medical Center. He and his family moved to Redlands in 1965, where he joined Doctors Harold Hill and Clarence Paul in the practice of Internal Medicine. Three years later, he moved his office to San Bernardino, taking over the Hematology practice of Dr. Philip Loge. He co-founded (with Dr. William Skoog) the Inland Hematology Oncology Medical Group and was its President until his retirement from full-time practice in 1995. He has served as the President of the Medical Staff of St. Bernardine Medical Center and as President of the Board of the Blood Bank of San Bernardino-Riverside Counties. After retirement he served as the Medical Director of the St. Bernardine Hospice for two years. Subsequently, he has been President of the Friends of the A. K. Smiley Public Library and the Watchorn Lincoln Memorial Association Boards and has also served as co-Lay Leader (with his wife, Helen) of the First United Methodist Church of Redlands. He and Helen have been married for 55 years. They have 3 children and 6 grandchildren.
VACCINES AND THE ANTIVACCINATIONISTS
Vaccination has saved more lives than any other medical intervention. Smallpox, which killed hundreds of millions during the course of history, has been eradicated. Polio has been eliminated from the United States and most of the world. Previously common infectious diseases have become uncommon. The recently developed Human Papilloma Virus (HPV) vaccine promises to markedly reduce the incidence of cervical cancer. Despite all these and other successes, there have been antivaccination movements from the time of the first vaccine.
SMALLPOX
The first vaccine was that against smallpox. The word “vaccine” is derived from the Latin “vacca” meaning cow, cowpox being the source of the smallpox vaccine. Edward Jenner, a country doctor in southern England, is given credit for developing the smallpox vaccine. One of the milkmaids in the area told Jenner that after she developed blisters on her hands from milking infected cows with similar lesions on their udders, she seemed to be protected from the periodic smallpox epidemics which she was exposed to. In 1796, Jenner did his famous experiment in which he collected fluid from a cowpox blister and injected it under the skin of 8 year-old James Phipps. Six weeks later, Jenner injected the boy with pus from an active lesion from a patient with smallpox. Remarkably, Phipps did not become ill. After doing other similar experiments, Jenner published his findings, which were translated into multiple other languages. The reason for the success of the cowpox vaccination was not understood at that time, the germ theory of infectious disease not having been developed until the late 19th century. By 1820, deaths from smallpox in England had been halved. The death rate continued to decline until 1852 when there was a significant increase in smallpox deaths both in London and also in the whole of England and Wales. Parliament responded by passing a compulsory vaccination law. Initially there was no enforcement of the measure and vaccination rates did not improve. Much tougher penalties were enacted in a law passed in 1867. If parents didn’t have a certificate indicating that their child had been vaccinated, they were given a warning. If the warning was not acted upon, the parents could be fined, and if they couldn’t pay, their assets could be seized and sold at public auction. If not enough could be raised, one of the parents could be jailed for up to 2 weeks.
The first significant anti-vaccination movement came about primarily in response to these tough compulsory vaccination laws. In 1866 the Anti-Compulsory Vaccination League (ACVL) was established. Membership in the League grew to 10,000 members by 1879 and by 1900, another 200 anti-vaccination societies had been established. The vaccine itself was accused of causing illness and death. The contents of the vaccine were claimed to contain among other things the excrement of bats and toads. Doctors were likened to vampires. Other elements in these anti-vaccination movements included large public rallies, paranoia, bizarre claims of vaccine harms (there were claims that the smallpox vaccination turned children into cows!), and claims that vaccines are unnatural and an act against God.
This initial anti-vaccine movement eventually forced the government to pass a conscientious objection law in 1898. Vaccination rates fell and deaths from smallpox rose in England. The famous physician, Sir William Osler, in 1910 expressed his frustration with the antivaccinationists by publicly offering to take 10 vaccinated and 10 unvaccinated individuals with him into the next severe smallpox epidemic. He offered to care for those who were unvaccinated and contracted the disease and to arrange for the funerals for those who died.
In 1899, a smallpox outbreak began in a suburb of Boston and subsequently spread to Boston and other nearby communities. The Cambridge Board of Health ordered all inhabitants of the city to be vaccinated. Those who refused were fined $5. Eventually the epidemic infected 1600 and killed nearly 300. One citizen, Henning Jacobson, refused to be vaccinated and also refused to pay the fine. He was tried in a local court and found guilty. He appealed, with the case eventually going all the way up to the United States Supreme Court. Jacobson’s attorney argued the requirement of vaccination violated the 14th amendment, depriving Jacobson of his liberty to decide what was best of his own health. The Supreme Court ruled against Jacobson by a vote of 7 to 2. Justice John Marshall Harlan in his majority opinion wrote in part: “ There are manifold restraints to which each person is necessarily subject for the common good. Society based on the rule that each one is a law unto himself would be confronted with disorder and anarchy.”
Anti smallpox vaccination groups appeared in the Unites States beginning in the 1890’s. Some groups concentrated on the “medical tyranny” of compulsory vaccination, while others were spearheaded by two parents whose children died after receiving a smallpox vaccination. In both cases, the children almost certainly died of other causes.
Fortunately, the power of the anti-vaccine movement eventually waned. By 1930, the need for smallpox vaccination had lessened and most of the charismatic leaders of the anti-vaccination movements had died.
After an intensive effort by the World Health Organization (WHO) beginning in 1967, the natural disease was totally eliminated by 1977. The last known case of smallpox occurred in England in 1978 as a result of a laboratory accident. Subsequently, all known stocks of the smallpox virus were either supposedly destroyed or sent to the Centers for Disease Control and Prevention (CDC) in the United States or the State Research Center of Virology and Biotechnology in Russia. Since 9/11, worries have surfaced that some countries or groups might have kept supplies of the virus. The United States maintains enough vaccine to vaccinate every single person in this country in case of an emergency.
PERTUSSIS (WHOOPING COUGH)
Whooping cough was a devastating infection before the development of a vaccine. About 300,000 cases occurred yearly, with 7,000 deaths.
The initial pertussis vaccine was prepared by killing whole pertussis bacteria with an antiseptic. It was tested in 1939 and found to be effective. In 1948, the pertussis vaccine was combined with the diphtheria and tetanus vaccines, initially known as the “DTP” vaccine, later also as the “DPT” vaccine. The pertussis vaccine was “a crude brew”, containing more than 3,000 pertussis proteins, which caused the vaccine to produce more side effects than any other vaccine. A study done by Dr. Larry Baraff of the UCLA Medical Center demonstrated that of every 10,000 children vaccinated, 6 had seizures with fever and 6 had decreased muscle tone and responsiveness lasting a few hours. Although these symptoms were terrifying to the parents, they did not definitely appear to cause permanent problems.
In 1973, Dr. John Wilson, at a medical meeting in London, presented a paper in which he described severe permanent neurologic problems following pertussis vaccination in 50 children. The report was influential in causing almost half of the general practitioners in England to stop recommending the vaccine. The rate of immunization in British children fell from 79% to 31% by 1977. Predictably, a severe epidemic ensued with over 100,000 children developing whooping cough, of which 36 died. Then in 1982, in the United States, a television program entitled “DPT: Vaccine Roulette” also presented a series of children with alleged brain damage occurring after receiving the vaccine. This program was a primary factor leading to the modern anti-vaccination movement in this country. Numerous lawsuits were filed against vaccine manufacturers, with many judgments in the millions of dollars. In response to those losses, most of pharmaceutical companies previously making the vaccines ceased production of them. An increasing resultant shortage of vaccine caused Congress to pass the National Childhood Vaccine Injury Act in 1986. This act protected the pharmaceutical companies from litigation by creating a federal no-fault, non-adversarial alternative to court suits. A trust fund financed by a surcharge on vaccines was created to pay vaccine victims. The act also required that doctors give benefit and risk information before vaccinations are started and that they report serious health problems following vaccinations to a centralized federal agency. Initially, almost any injury following administration of the pertussis vaccine was compensated, but, as subsequent studies failed to confirm a link between the vaccine and permanent neurologic damage, the bar for damages has become higher.
Fortunately, the rate of pertussis immunization in the United States never fell to that seen in England, although in certain communities the immunization rate is very low. Several of these communities have suffered significant outbreaks of whooping cough. In the 1990’s, pertussis vaccines having fewer side effects, known as “DTaP”, were developed containing only two to five pertussis proteins. In 2012, there were more than 41,000 cases of whooping cough, the highest level in 50 years. There were 18 deaths, mainly in infants less than three months of age. In addition to a decrease in “herd immunity”, part of the reason for the apparent increase in the incidence of pertussis in recent years may be that the newer vaccine may not be as effective as the older vaccine (DTwP). In order to protect infants until they are old enough to receive their own vaccinations, the CDC Advisory Committee for Immunization Practices (ACIP) now recommends that pregnant women between the 27th and 39th weeks of gestation receive the DTaP vaccine. Immunization of all household and day-care contacts of children less than one year is also recommended. There are ongoing discussions about modifying the vaccination schedule of the DTaP vaccine in children and even returning to the DTwP vaccine as the initial dose in the immunization schedule to improve the duration of immunity.
POLIO
Some of us remember a time when polio was endemic in the communities where we grew up. We all knew someone who had been paralyzed, including some who required an “iron lung” to breathe and we were fearful that we might be the next one to be infected. There was a community sense that something had to be done, since we were all vulnerable. Millions of dollars were donated to the March of Dimes for the development of a vaccine. Funding from the March of Dimes allowed Dr. Jonas Salk to develop a vaccine using killed poliovirus to develop an immune response. In 1954, the Salk vaccine was tested in a trial involving almost 2,000,000 children. When the positive results of the trial were announced, there was a national celebration with the ringing of church bells, moments of silence, special prayer meetings, and tears of joy by many. There, however, was one terrible malfunction. One of the vaccine manufacturers, Cutter Laboratories, failed to fully inactivate the virus in their vaccine. Of the 120,000 children that received Cutter’s vaccine, 70,000 suffered mild polio, 200 were paralyzed, and 10 died. When the Salk vaccine was properly prepared, with new regulations and oversight in place to prevent another Cutter incident, it proved to be remarkably effective and free of side effects. Cases of polio in the United States fell from 58,000 in 1952 to 1,312 in 1961. In the early 1960’s, the Sabin polio vaccine came into wide use, supplanting the Salk vaccine. The Sabin vaccine is a live vaccine in which the poliovirus has been weakened. It was also effective and had the advantage of being able to be given by mouth and of being much less expensive. By 1979, polio was eliminated from the United States and by 1991 it was eliminated from the Western Hemisphere.
There is, however, a rare problem with the Sabin vaccine. Occasionally the weakened virus may mutate into a virulent form and cause polio in the recipient. This occurs in an estimated one of 2.5 million doses. One such case was that of David Salamone, who developed paralytic polio in 1990 after receiving the Sabin vaccine. Further investigation revealed that David had a congenital immune deficiency which made him more likely to develop polio from the vaccine. David’s father John Salamone became an advocate for switching back to the inactivated vaccine for routine immunization. He founded an organization called Informed Parents Against Vaccine-Associated Polio (IPAV) and eventually appeared before the Institute of Medicine and later the Advisory Committee on Immunization Practices (ACIP) on several occasions. He often brought with him several children who had been paralyzed by the oral vaccine. His advocacy was instrumental in the reinstatement of the inactivated vaccine in 1998.
Efforts to eliminate the disease throughout the world have been spearheaded by Rotary International, which in 1979 made it their mission. Rotary has been joined by World Health Organization, UNICEF, the CDC, and since 2007 by the Bill and Melinda Gates Foundation, which thus far has spent over $1 billion on this project. Just two weeks ago, Michael Bloomberg pledged $100 million over six years to the Global Polio Eradication Initiative (GPEI). By January 2012, only three countries had endemic disease: Nigeria, Afghanistan, and Pakistan. One problem in northern Nigeria has been largely overcome. Four years ago, many small communities did not appear on the maps then available. Polio workers then walked through these remote areas and found 3,000 small communities which had previously been overlooked. Satellite imagery has created even more detailed maps. More recently, vaccinators have been provided phones with GPS which can be tracked to make sure that proper sites are being visited. Their efforts have been hampered by anti-vaccine propaganda, which has included claims that the vaccine transmits HIV and causes sterility. Just last month gunmen suspected of belonging to a radical Islamic sect shot and killed at least nine polio workers in Kano, the largest city in the north of Nigeria. Political instability in Afghanistan and Pakistan has hindered vaccination efforts there. In June 2012, the Taliban ordered that vaccinations in North Waziristan be suspended until drone attacks stop. In December 2012 and again in January 2013, medical aid workers were shot to death. The Taliban is thought to be behind the killings, although no group has claimed responsibility. Anti-vaccination efforts there have included the outlandish claims similar to those noted in Nigeria plus the allegation that the vaccination program is part of a Western spying network. The fact that a Pakistani doctor masquerading as a hepatitis vaccine worker played a part in finding Osama bin Laden has persuaded some parents that there may be credence to the spying claim. Other common reasons for parents refusing to have their children vaccinated include lack of knowledge about the vaccine, lack of faith in the effectiveness of the vaccine, and fear that the vaccine may contain religiously prohibited ingredients.
Last year (2012), only 223 confirmed cases of polio were reported world-wide, although there were undoubtedly many more asymptomatic infections. A final push by the GHEI to completely eliminate the disease by 2018 is underway. The goal is to raise $5.5 billion in the next year to finance this effort. It is anticipated that the origin of the funds will be a 50-50 split between private and public sources. The presidents of all three of the nations with endemic polio have given their support. There will be new efforts to gain the support of local Muslim leaders. The challenges are great, but if this project can be accomplished, it may well serve as a model for global vaccination and elimination of other diseases.
INFLUENZA
The Influenza viruses have been responsible for periodic pandemics which have killed thousands, and in some cases millions of people. The 1918 pandemic is estimated to have been responsible for 50,000,000 deaths. In 2009, a novel A/H1N1 virus appeared in Mexico and rapidly spread into the United States. This virus (“swine flu virus”) was thought to have been caused by a mutation in known Influenza A viruses. It was enough different from the usual seasonal flu viruses that pre-existing immunity was not present even in people who had received regular flu shots. A special vaccine was developed to produce immunity to the “swine” virus, which helped to limit the extent of the epidemic. Nevertheless, thousands of deaths occurred worldwide.
The seasonal flu vaccine is composed of three types of viruses, two of the influenza A type and one of the B type. Each year, experts from around the world identify the influenza viruses that are the most likely to cause illness during the upcoming flu season. The effectiveness of the vaccine depends to a large degree on the accuracy of those predictions. As of the first week in January 2013, most (91%) of the influenza viruses that have been analyzed at CDC are like the viruses included in the 2012-2013 influenza vaccine. Findings from data from a CDC report on February 21, 2013 suggest that this season’s vaccine is reducing the risk of having to go to the doctor for influenza by about 56% for vaccinated people. In those 65 and older, the vaccine effectiveness against outpatient medical visits due to laboratory- confirmed influenza A was only 9%. Despite being less than perfect, the flu vaccine is the best tool now available to prevent influenza. Seasonal influenza can be deadly, particularly in the very young and the very old and in other individuals with underlying medical conditions. The estimated number of yearly influenza-associated deaths in the United States varies from 3000 to 48,000. Treatment after the onset of illness using a neuraminidase inhibitor (Tamiflu or Relenza) is effective against most influenza strains if given within a few days of the onset of symptoms.
In order to protect hospitalized patients who are often frail and elderly, California state law requires hospitals to offer flu shots to their employees free of charge. Workers who decline the vaccine must sign a declaration. Redlands Community Hospital requires that its employees either receive the shot or, if they refuse, wear a mask when providing patient care. The medical staff has yet to formulate a definite policy for its members. Policies in other hospitals vary from no requirement to making vaccination a condition of employment.
Some opponents to the flu vaccine claim that it does not work. While it is true that the influenza vaccine is not as effective as other common vaccines, it does provide considerable protection, particularly to those under 65. Even if vaccinated patients develop the flu, it may be less severe than if they were not vaccinated, with a lower risk of associated complications. Others believe that the influenza vaccines themselves can cause the flu. The injectable form of the vaccine contains only killed virus and viral antigens and thus cannot cause an influenza infection. Randomized studies have revealed no increase in systemic reactions when the vaccine was paired against a placebo. An influenza-like illness occurring after vaccine administration does not mean that the vaccine caused the illness. The illness could be due to a non-influenza virus, or to influenza itself if the vaccine were not effective. The nasal spray flu vaccine, used primarily in children over the age of two, is an attenuated live vaccine with a temperature-sensitive adaptation which does not allow the virus to replicate at human body temperatures. Allergy to eggs is another reason that some refuse to take the vaccine. It is true that individuals with a history of a severe egg allergy should still avoid the vaccine. Those with a mild egg allergy are advised to take the vaccine with postvaccination observation for 30 minutes. Others refuse to take the vaccine because they are pregnant, have an underlying medical condition, or live with an immunocompromised person. In general, these groups have been specifically recommended to receive the vaccine. Finally some claim that they don’t need the vaccine because they never get the flu. While it is true that some people never develop the classic influenza syndrome when infected, having only minimal of no symptoms, they can still transmit the virus to others.
Research efforts to develop more effective influenza vaccines are ongoing. Vaccines containing two B strains as well as two A strains have been approved by the Federal Food and Drug Administration (FDA) and are expected to be introduced for the 2013-4 season. Other approaches to improving the vaccine include the use of adjuvants (additives), increasing the hemagglutinin content, and the development of cell-culture-produced vaccines. There is evidence that increasing the dose of the vaccine may increase its effectiveness.
VACCINES AND AUTISM
Autism is a developmental disorder that appears in the first 3 years of life, and is characterized by the lack of normal development of social and communication skills. The incidence has increased markedly in the last 30 years. Some of the increase may be explained by the development of more accurate criteria for the diagnosis of autism. The increase in the age of initial child bearing may also contribute to the increase in autism, but much of the cause for the increased incidence has remained uncertain. In 1998, Dr. Andrew Wakefield, a London surgeon, published a paper in The Lancet in which eight children developed autism after having received the measles, mumps, rubella (MMR) vaccine. All these children were said to have inflammation in the intestines. Wakefield’s theory was that the measles vaccine caused the inflammation, which in turn caused leakage of proteins from the intestines. The protein then, he proposed, traveled to the brain causing autism. Following this report, many parents in Britain and Ireland refused to have their children vaccinated with the MMR vaccine. Hundreds of hospitalizations and 4 deaths occurred in the measles outbreak that followed. Five of the eight children described in Wakefield’s report sued the manufacturers of the MMR vaccine. Wakefield received a large sum for serving as an expert witness in those cases. Subsequently, numerous well designed studies failed to find a link between MMR and autism. Finally in 2010, England’s General Medical Council censored Wakefield for subjecting the children to excessive procedures and also for his failure to get approval of the ethics review board prior to doing his studies. The Lancet then formally retracted Wakefield’s paper. Later in 2010, the General Medical Council barred Wakefield from practicing in England.
In the United States, questions arose has to whether the mercury containing preservative (thimerosal) in vaccines might be responsible for the rising incidence of autism. Subsequently, six large epidemiological studies were done, which showed no increase in autism in those children receiving vaccines containing thimerosal as compared to those who received vaccines free of the preservative. The fact that autism prevalence continued to climb after the elimination of thimerosol from all vaccines in 2001 was additional evidence that there was no link between the preservative and autism. In the meantime, eventually over 5,000 claims that vaccines caused autism were submitted to the National Vaccine Compensation Program (VICP). Fortunately, the special masters of the vaccine court relied on science rather than sentiment and ruled in 2009 that there was no evidence that MMR or other thimerosol containing vaccines caused autism.
The lack of evidence linking vaccines to autism has not deterred those who are absolutely convinced that their children’s autism is due to previous exposure to vaccines. Many celebrities, with Jenny McCarthy being the prime example, have been strident antivaccinationists. She has used her connections to appear on Oprah, Larry King Live, and other television programs, where she has voiced her unopposed opinions. McCarthy has been supported by a wealthy venture capitalist, J.B. Handley, who also has a son with autism. Handley has started the organization “Generation Rescue”, which advocates the use of chelating agents for treatment of autism. Chelating agents are approved for the treatment of heavy metal poisoning, but when used in situations where they are not effective can be dangerous. These agents have a long history of having been used by out-of-the –mainstream doctors for everything from heart disease to cancer, with no evidence that they have been helpful. McCarthy, Handley, and many other vaccine opponents are conspiracy theorists, believing that pharmaceutical companies, often in league with government and doctors, promote vaccines only to improve their profits.
COMMON FACTORS LEADING TO THE REJECTION OF VACCINES
1) Loss of Memory
After a time, vaccines become a victim of their own successes. Many are not familiar with the devastation caused by the diseases subsequently controlled by vaccines and now focus on side effects, most of which are imaginary. Some have forgotten or never knew the problems caused by hepatitis B, diphtheria, whooping cough, pneumococcal pneumonia, rotavirus infection, and Haemophilus influenzae type B infections. Others claim that the “usual” childhood diseases are benign and that vaccines against those diseases are not needed, but do not remember that measles can cause encephalitis and pneumonia, mumps can cause deafness, and rubella often causes birth defects.
2) The Power of Anecdotes
Anecdotes may be a generator of novel ideas in medicine. The observation by Jenner that milkmaids who developed cowpox skin lesions seemed to be immune to smallpox led to the development of an effective vaccine against smallpox. Anecdotes about a medical problem following a vaccination also have great power to those affected. However, the fact that one event follows another does not prove cause and effect. Coincidence is implied if it found that the problem in question occurs no more frequently in those vaccinated as compared to those who did not receive the vaccine. Despite evidence to the contrary, some will be continue to believe strongly that the vaccine was responsible for the bad outcome.
3) Distrust
Trust is institutions is at an all-time low. The recent important report from the Institute of Medicine indicating no major safety concerns associated with the current childhood immunization schedule is unlikely to influence the antivaccinationists. As noted previously, the advocacy of vaccines by governmental agencies, pharmaceutical companies, and doctors is thought by some to be a massive conspiracy. Some radical Islamist groups see a Western conspiracy to infect their children with HIV or to make them sterile.
4) Lack of Understanding of Community or “Herd” Immunity
When a critical portion of a community is immunized against a contagious disease, most members are protected because there is little opportunity for an outbreak. The percentage of immunization required to produce “herd” immunity varies with the disease. For polio, the critical immunization level is about 70%, whereas for the more contagious measles, about 95%. Community immunization protects those who have a contraindication to receiving that particular vaccine. Those who could receive the vaccine, but choose not to, also may get a “free ride”, unless they cause the percentage of immunization to drop below the critical level, in which case all non-immunized individuals are at risk. Those that believe that one has the absolute freedom to control what goes into his body and elects not to take a vaccine jeopardizes others as well as himself.
5) Religious and Philosophical Objections
There are some that find passages in the Bible that they believe vaccinations would violate. There are others who believe the illness is a mental and not a physical problem and therefore vaccines are not needed. Others object to the use of fetal cell lines, obtained from voluntary abortions, in the production of vaccines. The antivaccinationists have been successful in allowing those with religious and philosophical objections to opt out of mandates that vaccinations be given prior to admission to school. Religious exemptions are now allowed in all but three states; philosophical exemptions in 21 states.
6) The Modern Media, The Internet, and Social Networking
Television loves controversy. Anti-vaccine advocates, particularly those who are charismatic, frequently have access to shows to present their views, sometimes without an opposing viewpoint. Even if a scientist or public health official is on the program, he may not be as media friendly as an entertainer.
The internet allows everyone to have a platform to present his views, whatever they are. If one Googles “Are Vaccines Safe?”, two or three of the top ten sites which come up will offer a “no” answer. Social networking allows rapid dissemination of one’s opinions, whether supported by evidence or not.
7) Risk Adverse Society and Personal-Injury Lawyers
Personal-injury lawyers frequently sit on the advisory boards of anti-vaccine organizations, and often help them prepare material warning of the dangers of vaccines. Such material may also provide information about the process for collecting damages from the National Vaccine Compensation Fund.
REDLANDS UNIFIED SCHOOL DISTRICT’S VACCINE POLICY
In accordance with California state law, the Redlands Unified School District may not admit a pupil to school until he or she is fully immunized. Existing law, however, exempts a person from that requirement if the parent or guardian files with the District a letter or affidavit indicating that immunization is contrary to his or her beliefs. The RUSD requires two forms to be signed: one for the DTaP vaccine and one for the other required vaccines.
There is considerable variation in the percentage of personal belief exemptions among the different District elementary schools. Schools having fewer than 2% opt-outs were Arroyo Verde, Franklin, Highland Grove, Lugonia, and McKinley. In contrast, there were five schools with a more than 4% personal belief exemption rates: Cram, Kimberly, Mariposa, Mentone, and Smiley. It is difficult to draw definite conclusions from these data, although schools with more higher income families tend to have a higher opt-out rate which is consistent with a nation-wide trend. However, other schools despite having more lower income families also have a high exemption rate, the reason for which is unclear.
Beginning on January 1, 2014, there will be a change in the procedure for opting out of the requirement for immunization prior to school admission. AB 2109 which was passed by the Legislature and signed by the Governor on September 30, 2012 mandates that a visit to a health care practitioner for discussion of the benefits and risks of vaccination for those who wish to opt out of the requirement for immunization. A specific form prescribed by the State Department of Public Health is to be signed both by the health care practitioner and by the parent or guardian attesting that discussion regarding vaccines has taken place. This letter is to accompany the letter or affidavit previously required.
SUGGESTED STEPS TO INCREASE THE VACCINATION RATE
- Better Communication
The procedure of requiring a discussion of the benefits and risks of vaccines with a health care practitioner prior to opting out of the school admission mandate may convince some parents that vaccination is necessary. (Roll back of the current exemptions for religious and philosophical beliefs seems unlikely.) Research into the motivation for the opposition to vaccination policies may lead to new approaches to explain the need for vaccination. Accurate vaccination information to the public should be available in multiple languages, in a spectrum of reading levels, and in a variety of media.
- Continuing Scientific Studies
Research to improve the effectiveness and safety of vaccines needs to be expanded. Programs such as the Vaccine Adverse Events Reporting System (VAERS) and the Clinical Immunization Safety Network should be continued and perhaps strengthened.
- Scientific Literacy Education
Scientific principles need to be taught more effectively at all levels, from elementary school to professional schools, including law schools.
In closing, I’m offering a quote from Doctors Poland and Jacobson in their recent article in the New England Journal of Medicine: “Ultimately, society must recognize that science is not a democracy in which the side with the most votes or the loudest voices gets to decide what is right.”
BIBLIOGRAPHY
Book:
Paul A. Offit, Deadly Choices: How the Anti-vaccine Movement Threatens Us All, (New York: Basic Books Paperback edition, 2012).
Medical Journals:
Joseph Bresee, M.D. and Frederick G. Hayden, M.D., Epidemic Influenza-Responding to the Expected but Unpredictable, N Engl J Med 368:7: 589-592, February 14, 2013.
Gregory A. Poland, M.D. & Robert M. Jacobson, M.D., The Age-Old Struggle against the Antivaccinationists, N Engl J Med 364:2: 97-99, January 13, 2011.
Stefan Riedel, M.D., PhD., Edward Jenner and the History of Smallpox and Vaccination, Proc Baylor Univ Med Cent 18(1): 21-25, January 2005.
Eugene Shapiro, M.D., Acellular Vaccines and the Resurgence of Pertussis, JAMA: 308, No. 10: 2149-2150, November 28, 2012.
Thomas Talbot, M.D. & Keipp Talbot, M.D., Influenza Prevention Update: Examining Common Arguments Against Influenza Vaccination, JAMA 309, No. 9: 882-883, March 6, 2013.
Newspaper & Magazine Articles:
Bill Gates, My Plan to Fix the World’s Biggest Problems, Wall Street Journal, January 26-27, 2013.
Jeffrey Kluger, Polio & Politics, Time Magazine, January 14, 2013.
Michael Bloomberg & Bill Gates, Our plan to Eradicate Polio, Wall Street Journal, February 28. 2013.
David Ropeik, Not Vaccinated? Not Acceptable, Los Angeles Times, July 18, 2011.
Jay Winsten & Emily Serazin, Rolling Back the War on Vaccines, Los Angeles Times, February 7, 2013.
Websites:
U.S. Centers for Disease Control and Prevention (CDC)
FIGURE 1. ELEMENTARY IMMUNIZATIONS BY SITE
| Elementary school site | Total exemptions | Medical exemptions | Personal belief exemptions |
| Arroyo Verde | 1.57% | — | 1.57% |
| Bryn Mawr | 2.40% | 0.25% | 2.15% |
| Crafton | 2.60% | — | 2.60% |
| Cram | 4.80% | 0.58% | 4.22% |
| Franklin | 2.07% | 0.14% | 1.93% |
| Highland Grove | 0.98% | — | 0.98% |
| Judson & Brown | 2.56% | 0.16% | 2.40% |
| Kimberly | 4.34% | — | 4.34% |
| Kingsbury | 3.43% | — | 3.43% |
| Lugonia | 1.99% | 0.13% | 1.86% |
| Mariposa | 5.96% | 0.94% | 5.02% |
| McKinley | 1.71% | — | 1.71% |
| Mentone | 5.49% | — | 5.49% |
| Mission | 3.03% | — | 3.03% |
| Smiley | 4.70% | 0.27% | 4.43% |
| Victoria | 2.64% | 0.16% | 2.48% |