Vaccine Talking Points
by Dr. Cynthia Cristofani
She is a pediatric intensivist (read her FRONTLINE interview) who takes care of children in critical condition. She decided to start documenting with videos the rare cases of vaccine-preventable illness that turned up in her Portland, Oregon ICU.
I. The diseases which vaccines prevent are worse than possible side effects of the vaccines
And they aren't gone! Many occur regularly in the U.S. and they are much more common in the Third World -- which is only a plane flight away. In fact, there really is only ONE world, and it's getting smaller.
II. Vaccines are a clever way to stimulate NATURAL immunity
The antibodies patients make are their own, which is much more natural -- and effective -- than trying to treat the diseases with antibiotics and other drugs. (Even more unnatural, of course, is putting a child in an intensive care unit with all of the invasive life support measures that are used there.) Apart from the potential side effects of the medications and treatments we use to fight these diseases, the pathogens mutate and become resistant at a depressingly rapid rate, which means that our therapy becomes ineffective.
III. My background
A. I'm not an infectious disease expert. However, I graduated from medical school in 1975, which was before many of the current vaccines were developed. I have thus treated many more patients with these illnesses than younger physicians are likely to have seen.
B. As a hospital-based physician, I see patients who are much sicker than those who are well enough to stay home. Children with devastating meningococcus are much more likely to be encountered in a PICU than in an office practice -- never mind the public arena.
C. My father had polio as a child; when he was born in 1909, there was no vaccine for polio. (The eventual development of a polio vaccine was a major triumph of public health, and terrified parents begged to get it for their children before it became widely available.) Papa limped for most of his life, but at least he survived and did not need an iron lung.
IV. What about herd immunity?
A. It is of NO USE for some illnesses, such as tetanus, which is in the soil around us.
B. It is incomplete, because there are many unvaccinated individuals in the population (and the vaccines aren't 100 percent effective). Thus there is no guarantee that a susceptible child won't contract the infection. How would a parent feel if his child died of pneumococcal meningitis or survived with multiple amputations as a result of overwhelming meningococcal sepsis because vaccinations had been withheld?
C. Community spirit mandates consideration of ALL children in the community. For example, vaccinating one's own children is a way to assure that they don't transmit varicella (chicken pox) to a leukemic classmate who could die of it. "Hiding in the herd," i.e., assuming your child will be safe because all of the other children's parents are conscientious, is selfish.
V. Why can't we just watch him carefully and get him to medical attention if he gets sick?
A. In the early stages, most of these illnesses resemble all of the other relatively benign childhood afflictions. Fever, irritability, runny nose, headache, and vomiting are COMMON -- and most families are told NOT to bring their child to the doctor for every trivial infection. (In addition, of course, many American families have no health care insurance and try to treat their children at home rather than seeking medical care.) Only when the child is comatose, blue and gasping, convulsing, or covered with purpura does it become obvious that he is in catastrophic danger, and by then, it may well be too late.
B. Infants are the most vulnerable of all:
1. Their innate immune defenses are incompletely developed.
2. They are too young to have received their full set of vaccinations, even if their parents are conscientious and plan to immunize them.
3. They have very few ways to demonstrate that they are becoming ill. Pediatrics is VETERINARY MEDICINE in early childhood, since young children can't talk or offer specific complaints. In addition, other signs of serious illness may be absent; for instance, young infants with meningitis often DO NOT have neck stiffness.
4. Even if they are kept at home, they are likely to have older siblings who bring infections home from friends or classmates.
C. The diseases can progress with appalling rapidity: A child with meningococcus can easily die within 12 hours of onset of symptoms.
D. Treatment isn't necessarily successful, even though we do our best.
1. We have very few antiviral agents, and they tend to be less effective than antibiotics are for bacterial diseases.
2. Even if a child has a bacterial infection for which we have good antibiotics, killing the germs is only a small part of the battle. The toxins the germs release are usually the source of the overwhelming disease, and those effects continue even after the bacteria have been killed.
V. The diseases
A. Hib (Haemophilus influenzae Type B; "H flu")
1. NOT influenza -- despite the name; a bacterium which used to be a major cause of pediatric illness when I was in training.
2. Can cause a wide spectrum of illnesses, most of them serious
b. Sepsis with overwhelming shock
c. Epiglottitis (which can result in suffocation or brain damage from lack of oxygen)
e. Pericarditis (infection around the heart)
f. Peri-orbital (or orbital) cellulitis
g. Cellulitis of the cheek
h. Bone or joint infection
i. Ear infection
3. Hib vaccine first came out in 1987; a later version which could be given to younger infants was released in 1990 -- thank heavens!
4. In the old days, treatment was not necessarily benign; we used ampicillin and chloramphenicol, even though we knew that the latter could cause fatal bone marrow failure. For epiglottitis, standard treatment was to place a tracheostomy in order to assure that the child could breathe.
5. Hib disease is significantly less common than previously -- thanks to vaccines -- but it isn't gone. There was an outbreak in Minnesota in 2008, and 5 children got it -- of whom 1 died (i.e. 20 percent mortality!) The fatality occurred in a child who was not immunized. Herd immunity is not reliable even for Hib disease.
B. Meningococcus (Neisseria meningitidis)
1. Not terribly common (overall 1400-2800 cases in the U.S. per year), but probably the most dreaded of these infections, given the devastating illness it can cause.
2. Peaks of illness occur in infants -- for whom there is no vaccine -- and among teens and young adults. The vaccine does not, unfortunately, cover Type B (the most common cause of the disease in infants), but it does protect against the other strains of Neisseria, which are common in the U.S. and are more likely to cause disease in older patients.
3. Invasive disease is usually either meningitis or infection in the bloodstream (sepsis)
a. Meningitis results in fever, terrible headache, stiff neck (this does not occur in infants), vomiting, sensitivity to light, and alteration in consciousness in most patients. Many patients also have a rash, though this is less prominent with meningitis than with sepsis. Severe complications include brain damage or death.
b. Infection in the bloodstream may result in overwhelming shock, which is MORE dangerous than meningitis. Patients with this illness classically have fever, purple-spotty rash, muscle aches, and signs of shock (e.g. rapid heart rate, low blood pressure, cold hands and feet, kidney failure, and eventually, decreasing consciousness.) Septic shock has a significant mortality, even with the best of modern intensive care, and survivors may well end up with amputations, skin grafting, brain damage, and other permanent sequelae. At the least, a child with severe septic shock from this organism is likely to be on a ventilator, have tubes in every orifice, and be rendered unconscious with medications in an intensive care unit for days -- if he's lucky enough not to die shortly after presentation. Survivors may well go on to require multiple amputations, skin grafting, and weeks of rehab.
1. Along with meningococcus, one of the two commonest causes of bacterial meningitis outside the newborn period.
2. Can also cause sepsis with shock, pneumonia, ear infections, peritonitis.
3. Most likely to be lethal in a child with no spleen, but can cause devastating illness or death even in a normal child.
4. Signs and symptoms of meningitis and septic shock are similar to those noted for meningococcus, with the exception that the spotty rash is not typical of pneumococcus.
5. Pneumococcal pneumonia may result in pus around the lung with need for a chest tube or surgical intervention in addition to causing significant respiratory distress or failure.
6. Pneumococcus, unlike meningococcus, is developing resistance to commonly-used antibiotics. This makes treatment even more difficult and is another reason to advocate for prevention rather than treatment.
D. Varicella (chicken pox)
1. A viral illness -- hence it is not amenable to antibiotic therapy.
2. Doesn't kill most American children, but can result in significant suffering for the victim and family, lost work time for caregivers, and high risk for vulnerable contacts such as classmates with leukemia or those on chronic steroid therapy.
3. Even apparently healthy victims may suffer severe complications, including:
a. Superinfection with Streptococcus or other bacteria; can lead to shock, multiple organ failure, or death
b. Pneumonia can be severe and even fatal
c. Encephalitis or cerebellar ataxia
d. Reye syndrome if aspirin is inadvertently administered for the fever or pain
1. The most common cause of severe gastroenteritis in the world -- and a significant killer in the Third World; about 500,000 children die of this disease annually, mostly in infancy, and mostly in impoverished countries. Deaths are uncommon in this country, but the illness is still burdensome: Pre-vaccine, it resulted in an estimated 410,000 physician visits, 205,000-272,000 emergency department (ED) visits, 55,000-70,000 hospitalizations, and total annual direct and indirect costs of approximately $1 billion the U.S.
2. What is the illness like? It results in severe gastroenteritis, with:
c. Severe watery diarrhea
d. Irritability (and presumably crampy abdominal pain, though young children can't report this)
e. Severe dehydration can result in shock
f. Inability to eat may result in hypoglycemia in some young children
3. Prior to vaccine, there was near-universal infection of American children by age 5. Most infants with this disease are not sick enough to hospitalize (but are still miserable, as are their parents, who must try to comfort them, keep them clean, and keep them hydrated/nourished.) Those who do require hospitalization are likely to endure multiple pokes for IV insertion (or insertion of needles directly into their bones) in addition to the ongoing discomfort of the disease itself. IV placement is especially difficult in these patients because the veins of an infant are smaller than those of an older child and because infant veins are likely to collapse in the wake of dehydration.
F. Other (tetanus, measles, rubella)
a. Still present in the U.S. despite the vaccine. Cases now are usually in sporadic outbreaks, and the original source is often a patient in another country where measles is still common.
b. Highly contagious.
c. A MISERABLE illness; even though most American children survive, they suffer! (Significant mortality in the Third World -- up to 200,000 people per year die).
d. Ear infections and pneumonia are the most common complications, but some patients develop a brain infection (encephalitis), which can result in a seizure disorder, retardation, or hearing loss. A rare brain problem which can result in SSPE, a disorder which is a delayed consequence of early childhood measles infection. Victims of SSPE develop inexorable decline of personality and intellect as well as myoclonus (abnormal muscle movements) and go on to die, often within a year or two.
a. A disease for which there is no herd immunity whatsoever.
b. Largely eradicated in the U.S., but is still a killer in the Third World, where neonatal tetanus is continuing to kill (WHO estimates 180,000 neonatal deaths due to tetanus in 2002). Apart from home deliveries in unclean settings, infants in impoverished countries are endangered because their mothers are likely to be unimmunized and thus unable to provide placental antibody protection. If significant numbers of American girls do not receive tetanus vaccine, their infants will be at risk in future years.
A. The word's dangerous infections may have been suppressed in this country, but they haven't been eradicated.
B. The dangers of the illnesses for which they were designed significantly outweigh the infrequent potential complications of the vaccines.
C. Myths about vaccine dangers have resulted in significant numbers of children who are at risk for serious contagious diseases, and they have also regrettably diverted research attention and dollars from the REAL causes of autism and other serious disorders.