the vaccine war
COMMENTS

Interview: Cynthia Cristofani, M.D.

Cynthia Cristofani, M.D.

A pediatric intensivist, she takes care of children who need critical care. Cristofani decided to start documenting the rare cases of vaccine-preventable illness that turned up in her Portland, Oregon ICU. This is the edited transcript of an interview conducted on April 1, 2010.

Do you see children who have cases of vaccine-preventable disease?

I'm old enough to have seen most of the serious life-threatening illnesses that are largely suppressed, and some almost eradicated, by the modern vaccines. And I can tell you they're a true miracle of modern medicine.

I remember some of the dreadful diseases from when I was in training. Hib [Haemophilus influenzae type b], for instance, was the scourge of our existence. It was one of the most dangerous illnesses that we saw regularly. It was a common illness. The kids who came in often had meningitis, which means brain infection. They came in comatose, convulsing. If they were awake enough, we actually were reassured that perhaps their outcome was going to be better. But the kids who were awake were in miserable pain, because it's the worst headache of your life. They had stiff necks. They didn't want to be touched. They cried and cried, and of course they were too young to understand what was going on. And so the disease itself was terribly painful, and then the things we had to do to them were even worse in many regards.

In those days, we had to use IV [intravenous] antibiotics every six hours. We didn't have the new antibiotics that you can administer once or twice a day, which means that they had to be in the hospital for their entire 10-plus-day course of therapy getting multiple IV pokes, multiple drug doses. ... At the end of that ordeal, the children got yet another spinal tap to see if their spinal fluid had cleared and no longer was growing germs. Usually it was, but not always, because the antibiotics weren't as good in those days.

So a child with meningitis in those days was looking at a protracted hospital course, lots of pain, lots of needle pokes, and at the end of that he might still have serious sequelae. He might be blind; he might be deaf; he might be retarded or have a seizure disorder. They didn't all go home normal, healthy children.

Vaccination could have prevented a case like that?

Had the vaccines been available in those days. It used to be one of the commonest potentially lethal illnesses we treated. Hib actually caused not only meningitis; it caused buccal cellulitis at the cheek, necrotizing devastating pneumonia, sepsis with shock, bone infections, joint infections. Almost every part of the body could be affected.

One of the other problems with Hib was epiglottitis, which most people still talk about in medical class because it was so terrifying, although it's largely eradicated. Epiglottitis is where the epiglottis, the covering over the entrance of the airway that's supposed to protect you from aspirating when you swallow, gets dramatically inflamed. It is so swollen and large that kids can't breathe. And I remember those kids well, because they'd come in leaning forward, mouths open. They wouldn't talk because it hurt too much. They wouldn't even swallow their own saliva, so they'd be leaning forward drooling, with desperate eyes pleading for help, because those kids were awake, and they knew they were about to suffocate, and some of them did. All of us knew that if you did the wrong thing, like tried to start an IV or draw blood or even look in the child's throat with a tongue depressor, you might precipitate a fatal arrest.

And so what we did with those kids was to take them to the operating room in a parent's arms, put them to sleep with inhalation anesthesia on a parent's lap, and then only after they were unconscious would we be able to do anything to try to help them. In those days we actually put a tracheotomy in the front of their neck. We put a hole in the front of their neck to give them a real able airway, because we knew without it they might suffocate and just die.

Eventually we learned that you could put a tube in the windpipe through the mouth instead, so they avoided that surgery, but it was still a life-threatening illness, and those of us who remember those days still shudder when you think of it.

All of those things disappeared where they have vaccine. I remember as the years went by, eventually I realized: ''Wait a minute. I'm not seeing these things anymore. Those kids have gone.'' And they keep telling the students in my classes, ''Sooner or later we're going to get to stop talking about epiglottitis because Hib vaccine has eradicated it.'' That's unfortunately not entirely true, because of course the germ is still in the community, and if the public becomes lax in vaccines, it can come back.

There was an outbreak of Hib disease in Minnesota in 2008. Five kids got it, including one who had epiglottitis, so even though I had thought for a while that herd immunity might protect the average unvaccinated child, the germ is still in the community. It could come back if we let it.

What is the difference between morbidity and mortality?

Many of these diseases, particularly the patients that I see in the intensive care unit, have significant potential for permanent damage, and that's morbidity. Some of these kids go home not the same children. Anything that affects the brain may leave permanent brain injury, so all forms of meningitis, whether it's pneumococcus or Hib or meningococcus, can leave the patient with significant permanent brain injuries: retardation, seizure disorders, loss of hearing, a variety of potentially permanent injury.

In addition, if the patient is hypoxic -- that is, he suffocates because he can't breathe effectively from whooping cough or epiglottitis or has a full cardiac arrest from septic shock, for instance -- then his brain may be horribly damaged by lack of oxygen. He may be permanently comatose and survive in persistent vegetative state and never be conscious at all. Those things are terrifying to most of us. ...

The kids with septic shock usually have intellectual integrity at the end, but they lose body parts, and the shock is so severe that fingers and toes or feet or all limbs may end up simply dying from lack of blood flow. If you've ever seen kids with meningococcus septic shock in an intensive care unit and looked at the black hands and feet that are cold and clearly lifeless, you realize that those children are never going to get those extremities back. ... That's something that the average family never wants to think about for their own child who's supposed to run and dance and play, and instead they find themselves talking about prostheses or how extensive the skin grafting will have to be in the burn unit because the child's skin has simply been destroyed by the infection.

Is that an exaggeration?

No. Oh, no. I'll tell you, meningococcus is the most terrifying of these diseases that we routinely confront, because any of us who have seen it know exactly what it can do. With full-blown septic shock, you're looking at mortality of 15 to 20 percent, but the survivors often have serious permanent injury. And to go the rest of your life without a hand, without either leg, is a permanent handicap. ...

What is whooping cough, and how do you treat it?

Pertussis is the formal name for whooping cough, and it's a disease that is now preventable and unfortunately is still very much with us, and there's several reasons for that. One is that the original childhood vaccines didn't confer lifelong immunity, so the kids who got properly immunized in childhood because they had conscientious parents, by the time they were teenagers, forget it. They're a reservoir of continuing infection in the community.

In 2005 they came up with a new vaccine, which we really hope will suppress or perhaps even eradicate whooping cough. Whooping cough is a human germ only -- no animal reservoir -- which means if we can make enough humans immune simultaneously, we could eradicate it from planet earth. Like smallpox, it would be gone, and no one would miss it.

Whooping cough is a particularly miserable disease. ... You cough and you cough and cough, and you cannot stop. Eventually you manage to inhale a little air, and that's the whoop. And if you don't inhale any air, you may pass out. If you do, you're likely to make the noise of the whoop and throw up, and then a few hours later or even an hour later you do it all over again. These spells happen many, many times a day, and they'll also wake you up in the middle of the night. So these people are sleep-deprived, miserable. They never know when the next attack is going to get them. ...

Just the mechanics of the cough will hurt. Adults get rib fractures. It takes a pretty brutal cough to break your ribs. Little kids will get hernias; they'll get rectal prolapse; they'll get bleeding around the eye; occasionally they get bleeding in their skull; they'll bite their tongues. They do all kinds of damage just from the mechanics of the cough, never mind the fact that these people are suffocating and miserable.

In the Third World, this is a huge killer. Somewhere between 200,000 and 400,000 people die a year. ... In the First World, most people don't die of it, with the exception of very young infants. People who have had no immunizations at all have very poor immune defenses. This is where most of the reported mortality in the United States happens. ...

What about those who can't be vaccinated?

They are highly dependent on everyone around them to be immune, and certainly one of the major public health recommendations is that people who have contact with infants should get vaccinated because they're dependent on all of us not to give it to them. ...

But the real problem with young infants is they're too young to vaccinate themselves; they don't get a good response to the vaccine in the first several weeks of life. And of course most of their mothers have no immunity, because the average woman of childbearing age in this country has no immunity to whooping cough, so she has no antibodies to share across the placenta. And so those babies are completely vulnerable, and they're the ones who are most likely to die of whooping cough.

Connect this to Vanessa [Fontan].

She was too young to be vaccinated. Her parents had every intention of vaccinating their daughter, but she was too young at the time she got sick. And she had what looked to everybody, including physicians who first saw her, like the common cold, and certainly the common cold is far commoner than whooping cough. The problem is that she went on to get the difficult spells where she simply coughed and coughed and coughed and couldn't inhale.

If you watch her on the video, even when she's not actively coughing, she's holding her breath. She's not breathing. I look at the video, and I keep saying, "Vanessa, take a breath, please," because we knew that a child of that age with an already narrow airway baseline who's not inhaling well could easily lose consciousness from lack of oxygen and perhaps die.

What is the diagnosis for Vanessa and the immediate intervention?

... If you look on the video, I've got her seated upright leaning forward, trying to open her airway, giving her all the oxygen I can. We're trying to suction the copious secretions that kids with whooping cough get so that at least she has enough airway that perhaps she can breathe through it. Mostly I'm trying to get her to calm down and relax and just breathe.

No one who's desperately air-hungry is likely to be calm enough to follow your instructions to breathe, and a baby that age simply can't be instructed to breathe, and so you do everything you can to keep them comfortable and hope that they'll settle down and relax. That's one reason actually we got Mom in fairly promptly, because of course parents can comfort babies far better than we can. But we still had to give her full medical attention. Had she not been able to breathe well, we would have had to actually anesthetize her and put a tube in and breathe for her. She was fortunate to get through breathing on her own, although it was dicey.

Did she come close to death?

Had she had a bad spell in a bad place, she easily could have died. Had she had a bad spell even in a good place, i.e., in the intensive care unit with a full team around, it's still possible to die of whooping cough even with full medical attention.

Talk about rotavirus.

Rotavirus is a very common viral form of gastroenteritis, and it's usually the little kids who get it. In this country, at least before the rotavirus vaccine became available, the little kids usually had had it at least once if not several times by the time they were 5, and so older patients were less prone to it because they'd already seen the disease many times.

The problem with rotavirus is it's highly contagious, and it gives young children just copious, watery diarrhea stools. They dehydrate. They lose all their body fluids out the bottom end, and they are left with horrible dehydration to the point of shock. The kids who are sick enough to get into the intensive care unit usually have full-blown shock. They're so depleted of fluids and salts in the body that they simply don't have enough blood flowing through their veins and arteries to keep circulation going to important parts. If you look at them, they have cold hands and feet, perhaps blue hands and feet. Even their skin is lax because it just doesn't have the fluids it ought to have in it. ...

It's a miserable disease, and these little kids [don't] understand why they just are stooling and stooling and stooling. They get horrible diaper rashes. I think they probably have abdominal pain, although you can't tell with a little baby. They cry and cry and are miserable.

And the things we do to them are not pleasant either. Most of these kids have small veins at best, and when they're dehydrated their veins are likely to be empty. ... When things are desperate, we put needles directly through the bone into the marrow, and that's how we start infusing fluids. And so many of these kids, the first taste of medicine they get is actually a very painful needle inserting into their bones so we can get enough fluids into the blood vessels to start regular IV's. And it goes on for days.

Some say it's hard to find someone who has died from diarrhea.

I have seen fatal rotavirus. It's not common. Most of the kids who are really sick recover in this country. In the Third World it's a huge killer. ...

What about chicken pox?

Chicken pox used to be a normal part of growing up, and it was widespread, and most children did contract the illness during childhood. The problem is that not every child did well. Most of the general public, and even most pediatricians, don't see the children who had devastating outcomes or died of chicken pox because those kids tend to cluster in intensive care units, and they're out of sight to the general public and not usually something that's immediately obvious to the average pediatrician in his outpatient practice either.

But the kids who got overwhelming complications from chicken pox truly had miserable courses. The kids who are most likely to do that are the kids with leukemia or other malignancies where their immune defenses are compromised. We used to say chicken pox is the kiss of death to a leukemic who hasn't had the vaccine or had the illness and gotten antibodies before he got leukemia. And those kids, if they were in the school system and anyone in the school got chicken pox, the families would probably pluck them out and keep them home, and tried desperately [to avoid it]. We used to try to prevent them from getting it with immunoglobulin and other things, but all of us knew that if a child with leukemia got chicken pox, he might well die of it.

I've also seen it kill kids who didn't have known immune deficiencies. All of those lesions of course itch, and it's the rare child who can make [their] hands not scratch, and when you break all those lesions, then all the germs that live on your skin normally can get into your body. There's a significant complication if strep or staph bacteria that normally live on people's skin get in the blood stream. And when these organisms get in the blood stream they can cause just as devastating septic shock as some of the more common organisms like meningococcus. ... I've certainly seen chicken pox kill ostensibly normal children, or come close to it.

No exaggeration?

... I know full well that the average child with chicken pox stays home, has a fever, is miserable, scratches all his pox, and his parents take time off from work and they nurture him at home, and eventually they'll get through it and everything is fine.

I'm looking at a specific class of kids who don't have run-of-the-mill, garden-variety chicken pox. These are the kids who are sick enough to be put not only in a hospital but in an intensive care unit, so that's a unique group of kids, and the things I'm saying are not an exaggeration for that population of children. It happens. The real problem is that you can't predict which child it's going to happen to with any reliability. ...

Tell us about tetanus and herd immunity.

When people talk about the fact that we have such good herd immunity in this day and age that you don't need to immunize your child because of the fact that all the other children in his class are protected and so they're not going to give it to him, [they] tend to forget that for some things there is no herd immunity. Tetanus is one of the most notorious. Tetanus is in the dirt, and if you're not immunized, it doesn't matter whether anyone else around you got it or not; you can get it. ...

Tetanus is one of the most unpleasant disorders for the people who have it because of all of the muscles cramp. It's uncontrollable spasm. Think about the worst cramps that ever woke you up in the night and then imagine all your muscles doing that. People break their bones from the cramps they're so profound, and it's an extraordinarily unpleasant experience.

In the Third World, tetanus still kills hundreds of thousands of babies, and the problem in the Third World is that most of the women are not immunized, so they have no antibodies to share across the placenta, and they're cutting the cord with non-sterile devices, and so the babies actually get tetanus through their umbilical cords -- high mortality with this completely preventable illness.

This could happen in the United States, too, if we start seeing lots of young women not getting vaccinated in childhood. By the time they get to be mothers, they will have no antibodies to share with their children either.

A baby girl who gets her vaccine is going to help her child in the future.

In this country, most women have tetanus antibodies because they've been vaccinated as children. But if we start seeing large numbers of children who are not immunized, the little girls who didn't get their tetanus vaccines by the time they reach childbearing age will have no antibodies to share, and their newborns would be at risk for tetanus.

How about measles and MMR [measles, mumps and rubella vaccine]?

Measles was another of the common childhood illnesses when I was growing up and when I was first in training. It usually didn't result in kids who needed to be hospitalized, but they were pretty sick at home: high fevers, cough, miserable, conjunctivitis -- that is, inflamed eyes. Pneumonia was a common complication, and that was usually enough to get them hospitalized. Most of them recovered. A few of them had encephalitis, and a few of them went on to develop a chronic sequelae of measles called SSPE [subacute sclerosing panencephalitis], which is where the brain is injured perhaps years later, and eventually brain function deteriorates enough that most of those patients went on to die. That was rare.

But measles itself was a serious illness that is now completely preventable. And again, in the Third World it kills lots of children to this day. In this country it's been pretty much suppressed, so it's rare to see measles, although we do occasionally. ... When we have pockets of people who refuse vaccination, if it gets into that social circle, a number of them can be infected, and so there have been little outbreaks here and there.

If you get the chicken pox vaccine, does that prevent you from getting shingles later?

If you get the chicken pox vaccine, then you shouldn't get the virus in your body. The people who get [herpes zoster] shingles are those who have had the infection with chicken pox, and the virus is latent in the nerve ganglia and so can pop out as a surprise years later. So the vaccine which keeps you from getting chicken pox leaves you with no residual chicken pox in your body and so should prevent zoster.

Talk about your job in the pediatric intensive care unit.

It truly is a different environment than most families have ever envisioned in their worst nightmares. We are doing our best to help kids survive illness or injuries that might kill them, but in the course of doing what we have to do to keep them alive, we also have some fairly unpleasant things that we have to do. Most kids who are sick enough to be in an intensive care unit have significant respiratory problems, may well be on a ventilator, and that means the child has a tube in his windpipe and is being assisted with breathing by a machine. There are several very unpleasant aspects of that from the child's standpoint. First of all, a tube in your windpipe is a huge irritant. People cough and gag, and they hate the feeling of the tube there. And they also lose their voices, so they cannot talk or communicate, and if the child is not old enough to write down his thoughts, he has no way to communicate with anyone around him except to grimace and just cry soundlessly, but cry and cry and cry. And so the reality is, we don't leave kids awake with tubes in their trachea. What we do instead is zone with medications so they're in sleep. ... We will zone with narcotics and sedatives, and they look comatose.

From the parents' perspective, it's horrifying to see your child unresponsive, unable to look at you or interact with you, and not know whether under the drugs he's really still there. We try very hard to convince the parents that yes, he's going to be all right; he's going to wake up if he can. But if he has meningitis or has had a cardiac arrest or something where the brain damage may be real, then we can't reassure the parent that their child is still there and will come back to them. They can't see their child's face properly because there's tape all over it. There are tubes in his nose, tubes in his mouth; there are likely to be big IV devices in the veins in his neck or the veins under his clavicle; his arms are likely to be restrained and on arm boards; he's likely to have a catheter in his genitalia, and so all kinds of tubes. The child has to be immobilized, restrained, because if he rolls over, all of those tubes can come out, and he could be seriously injured. And so the child is totally helpless, and the family looking on also feels totally helpless.

Every parent wants to be the prime figure in his child's life and his protector and his guardian, and the families in intensive care units instead are not in charge. They often feel superfluous or in the way, although we try to bring them in and integrate them. But when they're watching what's happening to their child, who seems to be completely under the care of the physicians and nurses and other medical staff, they feel as if they've totally lost control. And they know that at the end of all this, they may not get their child back. ...

Why did you start to pick up the camera inside the ICU?

... I love bedside clinical care. I'm in my element with a sick child who needs help, but I realized that I could reach a lot more children if I taught other medical people to care for sick children. And I also discovered that most physicians, nurses, respiratory therapists and paramedics don't have the option to see a lot of sick kids, because in the general scheme of things, sick adults are lots commoner than sick children. So most people who have never dealt with a critically ill or injured child are utterly terrified, and even though they're doing their best, they're likely to clutch and not know what to do next.

I also realized that many of these children's fates are determined in the first hour of encounter with the medical establishment. If you don't get enough oxygen in the child's brain, if you don't get enough fluid into his blood vessels to keep him improving the shock, he may well die or have permanent injury. I can't be there in the first hour for most kids. If you're in an intensive care unit, you receive patients who have been resuscitated elsewhere. And so the best way to help those kids is to teach all of the people out there how they can intervene most effectively and get therapy under way long before the child has ever come close to being transported to an intensive care unit.

So I started teaching, and the first group I actually started teaching regularly were paramedics. ... Of course paramedics practice in a very challenging environment. There are limited numbers of people. The average ambulance has two paramedics on it, and they don't have nearly the wealth of equipment that we have in the hospital, and they're practicing in circumstances which are at best trying and sometimes flat-out dangerous if there's traffic or fire or hostile bystanders.

And so paramedics are some of the most gallant folks in the world, who are doing their best in the most challenging of circumstances to keep patients alive, and paramedics don't by and large get to see a lot of sick children. Something like 10 percent of the average paramedics calls are children at all, and of those maybe 10 percent are ill. So most of them don't get much chance to see really sick children.

I began to realize if I wanted them to see what I saw, I needed to film it. You can take still photos, and everybody says a picture is worth 1,000 words, but I'll tell you, a video is worth 1,000 still photos. If you want to see respiratory distress and labored breathing, if you want to see seizures, if you want to see very slow skin blood flow, if you want to hear wheezes or stridor or noises of respiratory distress, you need real time. And so I actually picked up a camera in hopes of letting the paramedics see what I saw, even though they weren't in the IC with me, by bringing it to their classroom.

What would the impact be if the CDC [Centers for Disease Control and Prevention] or pediatricians showed videos?

I think it would be phenomenal. When I show my videos in classes, most of the pediatricians come to me afterward and say, ''If the parents of my patients could see those pictures, they would have no doubt that they need to immunize their children.''

The problem is that the diseases were eradicated before the best AV [audio-visual] equipment was available. Nowadays anyone can video anything on his cell phone, but that wasn't the case then. When I first started videoing these patients, I had to borrow the big hospital camera on a big console and wheel it into the room and took VHS tapes, which are difficult to edit. And frankly, it was a lot of trouble. ...

The CDC has a very important role to play, but its role up until recently has not been primarily public education. It's been, investigating these critical illnesses and doing research and figuring out how we can control them. The PR [public relations] aspect of the CDC's efforts, I think, has been more recently developed, and unfortunately by the time most people got around to realizing, "Wouldn't it be nice to have videos of these things?," the diseases had become suppressed enough that most people don't see them anymore. So I had the good fortune, if you will, to be in a place where these kids tended to collect at a time when I happened to be doing tapes to educate medical folks anyway, and so they happened to be among the many patients that I videoed just in the course of teaching.

Parents choose not to vaccinate because they think there is no longer a threat. I understand the community recollection for these diseases has largely disappeared, because people who are parents nowadays are young enough to have been unlikely to have the diseases or seen the diseases in childhood. It's most of us who are older who remember what it was like to have chicken pox. But we're not the parents of today, and so the parents of younger kids who are of vaccine age are unlikely to have had any personal experience, and unless the grandparents or others can tell them what it was like and happen to have had knowledge of somebody who had a severe complication, it's easy to imagine that these diseases are eradicated.

To be honest, there is hope that we could eradicate them, but we're in the in-between stage. They are not gone for the most part. Polio was almost completely eradicated, but there's still several countries in the world where it exists, and those places are only a plane flight away, which is why we still need to keep immunizing for polio until it's eradicated. ...

Since the diseases may be fading from medics' memories, will your videos change anything for them?

I think it gives them the memory. People are trying to develop improved techniques for teaching, and there are a variety of simulation mannequins where you can actually make the mannequin turn blue or wheeze or do some things trying to bring realism into it. But it's far more realistic to see a live child on a video gasping or seizing or doing those things that even the best of the simulation mannequins simply can't do. And so it's my attempt to plant my memories in the mind of someone else, so the next time he sees a child with that problem. he'll know what to do. ...

Are you helping equip pediatricians to talk with parents who believe in nonvaccination?

Many of the younger pediatricians simply have not seen these diseases. If they've come out of training in the last 10 or 15 years, many of these diseases had become infrequent enough that in an entire residency, you might not have seen measles or Hib disease or any of those illnesses. And so if you haven't the personal recollection of how awful they were, it's harder to be persuasive with parents who also have no personal recollection of how terrible diseases were. If you can share the experience with somebody who has seen them, I think you're likely to be more convincing.

Is the information misguided that parents are getting off the Internet?

It's unfortunate, of course, in a way, that there's absolutely no control over what appears on the Internet, and you could post anything you like --true or not -- and so it takes significant sophistication to wade through the wealth of information which is on there, some of which is wonderful, to figure out where the kernels of truth are and where the exaggerations or flat-out misconceptions are.

I know full well that the people who first became concerned about vaccines had nothing but good intentions. Originally people wondered, was there a real connection? And the possibility of a real connection aroused enough fear that the rumors spread, and once it became apparent that the science didn't support any connection whatsoever, it was much harder to undo the original terror that spread through the community. And so those original myths are still there, and they're hard to counteract. Conspiracy theories tend to be popular, and it's hard to undo that kind of damage. ...

What is the tragedy in the choice not to vaccine because of the autism fear?

I think it's actually a twofold tragedy. The families who are choosing not to vaccinate their children because they have this fear of autism or other sequelae are not actually making a choice between measles or autism. They're making a choice between whether their child who might or might not get autism irrespective of his vaccination status is also at risk for measles or meningococcus or Hib or any of the others. It's a false choice to assume you're choosing between autism or some uncommon but potentially devastating illness. So it's a tragedy that their kids are unprotected because their parents are choosing not to vaccinate out of fears that are unfounded.

The other tragedy is that the kids who have autism desperately need better research into why and, more important, what to do about it now. That research isn't being done, at least to the degree that it should have been, because most of the would-be research has been sidetracked on to this false path. Instead of the time and dollars and efforts that should have gone into finding the real cause of autism and coming up with a way to prevent or treat it, those dollars and hours have been lost.

Address the belief that healthy, organic, living children don't need to get vaccinated.

There's certainly benefits to living in the First World and having clean water and good medical care, and certainly breastfeeding is the best food for babies, and I'm thrilled that most American women are doing that. But that's not all the protection you need, because many of these diseases are respiratory. They spread from respiratory secretions, and whether or not your water is clean, the coughing child at the next desk in your child's classroom could still give him these illnesses. ...

That idea called ''hiding in the herd,'' is that a selfish thing to do?

Hiding in the herd assumes that all of the other parents vaccinate their children; therefore your child won't be exposed to these things. And you can do that and get away with it a lot of the time, because herd immunity certainly has gotten better for many of these things. There's no guarantee that herd immunity will protect your child, and it also does mean that you're not doing your part to protect the other children.

When people have chicken pox parties and actively promote the spread of that particular virus, for instance, they're taking a significant chance that the school-age older sibling of the baby who's now gotten chicken pox is going to give it to a classmate who could die of it. And so it's forgetting the fact that we're in a community and we all need to protect each other, not just our own children. ...

How do you advise parents to know what is a trustworthy source?

I'd be inclined to start with the professional organizations: the American Academy of Pediatrics, American College of Emergency Physicians, the CDC, the World Health Organization. These are major, respected organizations that are doing their best to offer credible, useful information. Those are probably the places to start. If you just Google a topic of interest, you'll find all kinds of things, some of them legitimate and some not, and the average individual who doesn't know who wrote that may not have the idea of how much trust he can put in it. But if you start at least with the major, recognized institutions, to their credit, they're trying to make information available to the public. They're trying to use modern information capabilities and put good Web sites on the Net that the public can access. So I think that's probably the place to start.

How has the Internet changed the doctor-patient relationship?

I think actually it's a very positive change to have families medically knowledgeable, interested, having questions. Eons ago, the physician was considered the source of all knowledge, and Mom and Dad were supposed to do exactly what their doctor said they were supposed to do for their child. That wasn't a healthy relationship, ... so I'm delighted that it's become more of a partnership, rather than an authority figure and the recipients of the instructions, because I think patient care is better when the families who know their child best and their home setting best are actively involved in telling the doctor: ''This will work for me. This doesn't work for me, and here's why. And by the way, I heard about this. What do you think?'' I'd much rather have a dialogue of knowledgeable, caring people involved in the management of a sick child than just a doctor telling the parents what to do.

How does the doctor handle the parents who don't believe in vaccination?

I'm fortunately never in that position because I don't do outpatient care. I know my colleagues struggle with it because they truly believe the children need to be vaccinated, but they also know the parents are caring people who are trying to do what is best. So most of them will bring in the best evidence in literature that they can and show the parents what they know from the medical perspective that might not be so obvious on the Web and do their best to educate. And it's what role they have to take.

How unique and difficult is what you're doing with the videos?

... As a medical person, my prime duty is to my patient, and I can't stop treating to go pick up a camera. And so essentially all the videos in my collection -- with the exception of Vanessa, whose father actually helped take some it, or the nurse who took it -- were taken by me, but they were taken after the patient was stable enough that I could put down what I was doing and go pick up a camera and video, which is why I don't have videos of acute resuscitations, because I'm doing the acute resuscitation, or [videos of] children who are convulsing and haven't had anticonvulsants or any therapy yet. It's hard to get pictures of a child who's really sick if you haven't done everything that he needs done first. ...

What impact has vaccine fear had on the progress of vaccine innovation?

This one is near and dear to my heart. I do worry that all of the vaccine controversy has dissuaded the manufacturers from pursuing new vaccines that we desperately need with the same zeal that they might have. I truly consider vaccines a major medical miracle if you think about what we can do to prevent medical illness. There are all kinds of things we can do to prevent trauma, from bike helmets to seat belts to personal flotation devices. There are not that many things that we can do to prevent medical illnesses. The ''Back to Sleep'' campaign to minimize the risk of SIDS [sudden infant death syndrome] has been a major pediatric one, but there aren't so many except vaccines. This has been a dynamite improvement in medical care. It's a miracle.

I would love to see the manufacturers get us a really good meningococcus vaccine. The one we have is pretty good, but it doesn't cover type b, which ... is the main strain that affects the little infants. It also can't be administered under the age of 2 years. If the manufacturers would give us a vaccine that we could use at 2, 4 and 6 months along with all the others, ... we could eradicate meningococcus and eliminate this terror from planet earth. So I would love to see the manufacturers developing new and better vaccines rather than focused on the controversy, or what they perceive to be the medical legal risk of even trying.

You say we need more/better vaccines, but the pharmaceutical companies will make money off of them. Isn't there a conflict of interest?

They don't make all that much money off the vaccines, I don't believe, and I cannot speak from the perspective of the pharmaceuticals, but I have little doubt that some of their other products are a lot more lucrative. ...

How do you explain the rare risks that CDC lists?

I won't tell you that vaccines are all harmless. A lot of people get a little local reaction at the injection site. Some people will get fevers, and an occasional child with a susceptibility for febrile seizures may have a seizure after he gets a fever from the vaccine -- not common, benign, but certainly it's something that makes parents nervous.

From the standpoint of the more serious complications, the CDC does keep very careful records of what look to be adverse effects of the vaccines. For instance, they stopped using the oral polio when it became obvious that some people were actually ... getting polio from the vaccine. So they're keeping track. And nowadays that polio is suppressed enough that you're not likely to come in contact with it, it's probably more dangerous to take the oral polio vaccine than not, and so people aren't using that anymore.

Guillain-Barré syndrome has a significant incidence in the public who hasn't been vaccinated, and so when you look at these things that might or might not be associated with vaccines, you always have to ask what is the baseline incidence in the general community, and is it higher in the wake of vaccines?'

And to their credit, they look very carefully at adverse events, which is why, for instance, when the earlier rotavirus vaccine looked as though it had a higher association with intussusception than was normal in the general population, they took it off the market. And so they are watching. ... The CDC is doing its best to make sure that any potential side effects are still not more serious than the actual disease that they're trying to prevent.

Are we seeing more autism?

I actually am not an expert on autism. Certainly it's being talked about and discussed more. Whether that's actual increase in incidence, which it may well be, or whether it's simply more recognition, I don't know. But there are many other diseases like multiple sclerosis that we also don't know the cause for, and it's certainly scary when something new comes on the horizon and you don't understand it. But it's too easy to make a connection that doesn't exist, and assuming you understand it, it's harder to admit you don't know, but we really don't. ...

Explain your quote: ''Vaccines are a clever way to stimulate natural immunity.''

Natural immunity is your body's ability to respond to an infection and make antibodies that will protect you from future recurrence in that infection. Most patients who had a disease develop some resistance to it, not always for life -- depends on the disease -- but they tend to be resistant to it or not likely to get it again, at least for a significant interval. Vaccines are simply a way to make the body think it's had the infection without really making the body as sick as it might have been with the real infection. This began with cowpox, when people discovered that smallpox, which was overwhelming and lethal, was similar enough to cowpox that if vaccinated with cowpox, people didn't get or die of small pox. And it's just another way of fooling the body into making vaccines. Sometimes when patients get overwhelming infections we try to give them gamma globulin -- that is, somebody else's antibodies -- but it's much nicer to let the patient make his own.

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posted april 27, 2010

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