Saturday, October 27, 2012

Deadly Choices - Review

Deadly Choices: How the Anti-Vaccine Movement Threatens Us All, by Paul Offit

"Individual Idiocy versus Collective Consequences"
5 stars
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Short Review: This is a scathing dismantling of the anti-vaccine movement, its pamphleteers, the dubious huckstery that passes of as science, the hysterical fear-mongering, the assault on science and reason, and the ultimate price paid by the innocent victims - defenseless children.
The book, written by a pediatrician - and an expert on vaccines, immunology, and virology (as per Wikipedia) - is very well-organized and takes us through the origins of the anti-vaccine movement in 1982 - April 19, 1982, to be precise, "when WRC-TV, a local NBC affiliate in Washington, D.C., aired a one-hour documentary titled DPT: Vaccine Roulette" - and to its even earlier origins in the nineteenth century in England. The people behind the anti-vaccine movement, while sometimes well-intentioned, remain captives to ideologies and biases - biases that have remained stubbornly resistant to science and evidence.  But this is not just a book about the anti-vaccine fundamentalists. The book also documents how herd-immunity suffers when mass-immunizations are compromised, when the "tragedy of the commons" afflicts healthcare. It also dismantles several of the claims made against vaccines - that too many vaccinations overwhelm the body, that there are huge quantities of dangerous chemicals injected into our bodies, that alternative treatments are just as effective - if not more, and some of the more insidious allegations - that vaccines cause autism, or that the pertussis vaccine to protect against whooping cough causes mental retardation.
What makes this book effective is its reliance on science and evidence to debunk the anti-vaccine movement and its champions. While there is undoubtedly a sociological element to this debate, this book chooses to leave that for another book or perhaps to another author.

The irony and tragedy of the the anti-vaccine fundamentalists' campaign is underlined by the fact that it foists a choice upon children - who are in no position to decide, to choose, or even refuse to be not vaccinated if they so wanted. More importantly, the agonizing and lethal consequences of such choices are visited on those least capable of defending themselves - children. It is this frustrating evil that makes such blind faith in dogma so infuriating, and unacceptable in a civilized society.

Long Review
While vaccination may be an accepted and immutable fact of modern childhood - a sometimes painful shot that protects children from diseases that just half a century ago would have killed or crippled hundreds of thousands of children every year - it is also undeniable that a concerted group of individuals are seeking to reverse these gains in child healthcare. This book takes a long, hard, and clinical look at the claims of the anti-vaccine fundamentalists, the falsehoods, deceptions, outright bad science, and tactics of intimidation that they have employed to further their cause, at the cost of leaving children vulnerable, unprotected, and sometimes facing avoidable death.

First off, the author does make it clear that there is space and a need for people who shine a critical light on the safety of vaccines - people like Joe Salamone, who helped change polio vaccination policy in the United States after his son was paralyzed after taking a weakened polio vaccine. In 1998 the US switched to the safer inactivated polio vaccine as a result of Salamone's efforts.

The fact is that as recently as the 1960s, "several vaccines had serious side effects, every year causing allergic reactions, paralysis, or death. Public health officials and doctors didn't hide these problems. But they didn't do anything to correct them, either. And most parents had no idea they existed." What could have been a story of opportunity becomes one of wasted chances in the case of the anti-vaccine brigade. An unremitting, unrelenting, dogmatic opposition to vaccines - to all vaccines - became the end, rather than a means of improving vaccines, disingenuous lip-service notwithstanding.

The airing of the documentary, "DTP: Vaccine Roulette" not only birthed the modern anti-vaccine movement, it also launched the career of its writer and producer, Lea Thompson, who went on to have a "meteoric" career, and who "won almost every major award in broadcasting".

A secondary consequence of the anti-vaccine movement was the equally meteoric and inevitable rise in lawsuits against pharmaceutical companies manufacturing vaccines, and the more than hundred-fold increase in money "requested by plaintiffs" (from $25 million in 1981 to $3.2 billion in 1985).
"In response, pharmaceutical companies increased the prices of their vaccines and scrambled to get liability insurance. In early 1982, DTP vaccine cost $0.12 per dose. In June 1983, the cost rose to $2.30; the next year, to $2.80. By 1985, the cost of one dose of DTP vaccine was $4.29—a thirty-five-fold increase in less than three years.
Pharmaceutical companies abandoned vaccines. In 1960, seven companies made DTP. By 1982 only three remained"
Some semblance of sanity was restored when on "October 18, 1986, the last day of the Ninety-Ninth Congress, legislators passed a bill that protected vaccine makers: the National Childhood Vaccine Injury Act. One month later, President Ronald Reagan signed it into law. The act contained the Vaccine Injury Compensation Program (VICP), which included a list of compensable injuries possibly caused by vaccines."

Herd Immunity:
While the obvious benefits of vaccinations are apparent - protecting children against diseases - there are other not so apparent advantages too. When done on a mass scale, once a "certain percentage of the population" has been vaccinated, "a phenomenon known as population or herd immunity" is achieved. "People who aren't vaccinated or who can't be vaccinated will be protected when surrounded by a highly vaccinated group." ... "The fraction of the population that needs to be vaccinated to provide herd immunity depends on the contagiousness of the infection. For highly contagious infections—such as measles or pertussis—the immunization rate needs to be about 95 percent. For somewhat less contagious infections—like mumps and rubella—herd immunity can be achieved with immunization rates around 85 percent."

This phenomenon of "herd immunity" has an unintended consequence. Think about it - if herd immunity is achieved, then a person living in that "herd" can enjoy the benefits of immunization without having to get himself or herself immunized, right? Yes."After enough people are immunized, those who aren't can hide in the herd, protected by those around them. Second: although vaccines are safe, they aren't perfectly safe."

Tragedy of the Commons:
And thus we come to the "Tragedy of the Commons".  As more and more people choose to avail of the free benefits of immunization, herd immunity itself breaks down.

Indeed, Robert Chen, "then head of immunization safety at the Centers for Disease Control and Prevention, created a graph titled "The Natural History of an Immunization Program"" that "described what happens when vaccines are used for a long time, partitioning the public's reaction into distinct phases." It is a depressing arc of four phases, and the "last and most disturbing phase of Chen's graph offers a solution to the problem posed by unvaccinated children. In this phase, the incidence of preventable deaths becomes so high that parents again seek solace in vaccines."

It would seem that absence does make the heart grow fonder. An absence of the devastating diseases eradicated through vaccinations makes the heart grow fonder for a return to high infant mortality rates and slow, painful, lingering deaths of children. Unbelievable.

Opposition to vaccines has undergone several changes in character, but the basic edifice of this campaign has been constructed on fear, ignorance, and dogma. While some activists "described vaccination as a perversion of the Christian sacraments", some described vaccination as ""unchristian," a type of "devil worship" that transformed a child into an "anti-Christ.""

Strange bed-fellows:
Today, the anti-vacciners can be found among "upper-middle class" and the "college- and graduate-school-educated", who believe that the Internet is the key to the acquisition of expert knowledge. They are helped down this path of perdition by self-proclaimed media blowhards like Bill Maher, and Playboy playgirls like Jenny McCarthy. Yes. Strange bedfellows for sure.  McCarthy for instance, came to the conclusion that while the MMR vaccine was indeed not responsible for her son's autism, her alternative explanation - "(autism) was caused by vaccine toxins—specifically, mercury, aluminum, and anti-freeze" - was rendered even more bizarre by her subsequent endorsement of toxins - ""I love Botox. I absolutely love it. I get it minimally, so I can still move my face. But I really do think it's a savior." Made by the bacterium that causes botulism, botulinum toxin [Botox] is one of the world's most powerful toxins.)"

Bill Maher wrote an article against vaccines in the Huffington Post, replete with errors. "He argued that polio was on the decline before the vaccine. In fact, in 1943, ten thousand Americans suffered polio; in 1948, twenty-seven thousand; and in 1952, three years before Jonas Salk's polio vaccine, fifty-nine thousand.
Finally, when Maher wanted to educate himself about vaccines he called on Barbara Loe Fisher (a media-relations expert), Russell Blaylock (a neurosurgeon), and Jay Gordon (an anti-vaccine pediatrician). Not one of his advisors is an expert in immunology, virology, bacteriology, epidemiology, or toxicology. And not one has ever published a single study on the science of vaccines."

The crusade against vaccines goes back two centuries. After vaccinations were made mandatory, legal challenges were mounted. These should have ended in 1905, when the US Supreme Court, "by a vote of 7 to 2 - ruled that the right to refuse vaccination wasn't guaranteed by the U.S. Constitution. Writing for the majority, Justice John Marshall Harlan argued that, in the arena of public health, societal good trumped individual freedom."

In 1944 the US Supreme Court again ruled on a similar matter in the case "known as Prince v. Massachusetts", where "Justice Wiley B. Rutledge, who wrote the majority opinion for the court, then went beyond the case in front of him: "The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death. Parents may be free to become martyrs themselves, but it does not follow that they are free, in identical circumstances, to make martyrs of their children.""

This ruling did slow down legal challenges to vaccinations and exemptions sought on religious grounds. However, the slow grind of political compulsions and relentless canvassing resulted in a slow erosion of these protections.
"By 2009, forty-eight states allowed religious exemptions to vaccination." 
Religious exemptions opened the door to philosophical exemptions.
"By 2010, twenty-one states allowed philosophical exemptions to vaccination."
All this was in the face of incontrovertible evidence that unvaccinated children were in serious danger of contracting entirely preventable diseases.
"In 1999, Daniel Salmon and co-workers from the Johns Hopkins School of Public Health found that the risk of contracting measles in five- to nine-year-olds whose parents had chosen not to vaccinate them was one hundred and seventy times greater than for vaccinated children."
Armchair Experts:
While journalists like Bill Maher could be perhaps excused, if not forgiven - he is a journalist on the lookout for made-up or real scandals, what do you say to members of the medical profession, who choose to stay uninformed, and then use the authority of their professional standing to spread disinformation? Prominent in this camp of the anti-vaccine brigade is a doctor, Dr. Robert Sears, who has written a bestseller - "The Vaccine Book: Making the Right Decision for Your Child" - that purports to soothe the frayed nerves of parents terrified by the thought of having their babies injected with too many vaccines. He proposes an alternative schedule of vaccination, based apparently entirely on his rigorous research of sitting behind his desk on his posterior and cogitating. He believes that it is better to give vaccines one at a time to children so that their bodies can cope and not get overwhelmed by the combined vaccinations delivered to children.
But consider this - "By the time babies are just a few days old, trillions of bacteria live on the lining of their intestines, nose, throat, and skin. Indeed, people have more bacteria living on the surface of their bodies (a hundred trillion) than they have cells in their bodies (ten trillion). And each bacterium contains between two thousand and six thousand immunological components."
"Sears implies that a baby's immune system isn't mature enough to respond to vaccines."
Really? Consider this: "It is rather remarkable that following passage through a birth canal containing literally billions of hepatitis B viruses, a one-day-old baby can mount a protective immune response to a vaccine that contains only twenty micrograms (millionths of a gram) of one highly purified viral protein."

This baseless fear mongering then turns to the presence of supposedly dangerous elements in vaccines. Like aluminium. Surely, no one wants their babies ingesting aluminium, do they?
"Although Sears claims that avoiding aluminum-containing vaccines is an important way to avoid aluminum, it's not. Aluminum, the third most abundant element on earth, is everywhere. It's present in the air we breathe, the food we eat, and the water we drink."

Or take formaldehyde, a "carcinogen". But then, "Everyone has about two and one-half micrograms of formaldehyde per milliliter of blood.
Further, the quantity of formaldehyde contained in vaccines is at most one six-hundredth of that found to be harmful to animals."

The most biting criticism against Dr Sears comes from the fact that -
"one has to question the hubris of a man who decides to create his own vaccine schedule—someone who claims his schedule is better and safer than that recommended by the CDC and AAP. It's all the more amazing when one considers that Robert Sears has never published a paper on vaccine science; never reviewed a vaccine license application; never participated in the creation, testing, or monitoring of a vaccine; and never developed an expertise in any field that intersects with vaccines—specifically, virology, immunology, epidemiology, toxicology, microbiology, molecular biology, or statistics."
The fact that such a person writes a book that sells does not bode well for an allegedly educated society.

Deluge or Delusion?
To consider the argument that too many vaccines can be overwhelming for a child, look at the first vaccine - smallpox.
The pertinent number to look at when answering the question of "too many" is "the number of immunological components contained in vaccines. Smallpox, the largest virus that infects mammals, contains two hundred viral proteins, all of which induce an immune response. Today's fourteen vaccines are made using viral proteins, bacterial proteins, and the complex sugars (polysaccharides) that coat bacteria. Each of these components, like viral proteins in the smallpox vaccine, evokes an immune response. The total number of immunological components in today's fourteen vaccines is about a hundred and sixty, fewer than the two hundred components in the only vaccine given more than a hundred years ago."
So, taking the argument further, just how many vaccines should be given in one go to children? And just how many vaccines could children, in theory, be able to cope with - i.e. what number of vaccines would exceed the "immunological capacity" of children? Would it surprise you to learn that "babies could theoretically respond to about a hundred thousand vaccines at one time"? This number is based on the result of work done by "two immunologists at the University of California at San Diego" who determined, that "Given the number of B cells in the bloodstream, the average number of epitopes contained in a vaccine, and the rapidity with which a sufficient quantity of antibodies could be made, babies could theoretically respond to about a hundred thousand vaccines at one time."

Brains not allowed:
Among the many charges leveled against vaccines, one of the more serious ones has been the claim that vaccines cause mental retardation, and not just in those making those claims. "In 2006, Samuel Berkovic evaluated fourteen people with severe epilepsy and mental retardation. All had developed their first seizures between two and eleven months of age; all had received the pertussis vaccine within the previous forty-eight hours"
"He found that eleven of the fourteen had a defect in the gene that regulates the transport of sodium in brain cells. (The specific gene is called SCN1A; and the specific disorder, a sodium channel transport defect.) "
Since "vaccines can't change a child's genetic makeup", this should have conclusively put to rest the wild claims of linking vaccines with mental retardation. And indeed, so exciting was this research that "Not a single newspaper, magazine, or radio or television program carried the story." Yes.

What about the more recent charge that the measles vaccine was linked to autism? This accusation, no, the research-backed assertion was asserted in 1998, by Andrew Wakefield, "a surgeon working at the prestigious Royal Free Hospital in London", who laid out the charge that "measles vaccine entered the intestines causing inflammation; once inflamed, the intestines became leaky, allowing harmful proteins to enter the blood, travel to the brain, and cause autism." This resulted in many parents choosing not to go for the MMR vaccine. In the United States alone, more than a lakh children were not given the MMR vaccinate as a result.

Even though "twelve separate groups of researchers working in several different countries" found no difference in the risk of autism between those "had or hadn't received MMR", it didn't end the scare.
It later turned out, thanks to the work of Brian Deer, "a journalist working for the Sunday Times of London", that "the parents of five of the eight children described in Wakefield's paper were suing pharmaceutical companies, claiming that MMR had caused autism. Deer also found that the personal-injury lawyer who represented these children, Richard Barr, had given Wakefield £440,000 (about $800,000) to perform his study, essentially laundering legal claims through a medical journal."

To err is human:
This is not to say that every single vaccine has been an unqualified success, from the very first vaccination onwards. No, there have been missteps, tragic missteps.
Like when in "1921, two French researchers, Albert Calmette, a physician, and Camille Guérin, a veterinarian, reasoned that a bacterium (Mycobacterium bovis) that caused tuberculosis in cows could protect people against human tuberculosis. They developed a vaccine later called BCG (Bacillus of Calmette and Guérin), a modified form of which is still used today. In 1929, however, 250 ten-day-old children in Lubeck were given a BCG vaccine that wasn't made of BCG. It was made of pure, highly lethal human tuberculosis bacteria. Seventy-two babies died from the mistake."

Or in "the early 1940s" when "a yellow fever vaccine was routinely given to American soldiers. Everyone got it. To make sure the vaccine virus was stable across a broad range of temperatures, manufacturers added human serum, a decision that proved disastrous. ... Unbeknownst to the manufacturer, some of the blood donors had hepatitis."

Even the polio vaccine, invented in the "early 1950s" by Jonas Salk, had a tragic debut trial.
"Working with mice and then monkeys, Salk figured out how to make a vaccine by growing poliovirus in laboratory cells, purifying it away from the cells, and killing it with formaldehyde. In 1954, the March of Dimes tested Salk's vaccine in a trial of almost two million children."
"When the March of Dimes had tested Salk's vaccine, it relied on two veteran vaccine makers: Eli Lilly and Parke-Davis. But when the vaccine was licensed for sale, three other companies joined in: Wyeth, Pitman-Moore, and Cutter Laboratories. It soon became clear that Cutter, a small pharmaceutical company in Berkeley, California, had made it badly, failing to fully inactivate the virus. As a consequence, one hundred and twenty thousand children were inadvertently injected with a vaccine that contained live, potentially deadly poliovirus: seventy thousand suffered mild polio, two hundred were severely and permanently paralyzed, and ten died."
So does one conclude that vaccine research is more art than science, and vaccine research is not subject to the same rigours as regular pharmaceutical research? Quite the opposite.
"HPV vaccine was tested in thirty thousand women, the conjugate pneumococcal vaccine in forty thousand children, and the current rotavirus vaccines in one hundred and thirty thousand children before licensure; all were tested for more than twenty years."
And what about fears about vaccines containing mercury that caused autism?
"In 1999, the American Academy of Pediatrics and the Centers for Disease Control and Prevention worried that children might be receiving too much mercury in vaccines, called for pharmaceutical companies to remove a mercury-containing preservative called thimerosal.
Again, the academic and public health communities responded, performing six large epidemiological studies
The results were reproducible and clear: thimerosal didn't cause autism. Consistent with these studies, after the spring of 2001, when thimerosal was taken out of all vaccines recommended for young infants, the prevalence of autism continued to climb."
So, to summarize - the accusation was that mercury in vaccines was causing autism. Mercury was not found to be linked to autism, yet was removed from vaccines, and guess what? No effect on the rates of autism. Case closed? No. Not at all.

The anti-vaccine camp marches on, undeterred by fact or science. Only the cheerleaders changed. Only the tactics changed. While opponents of vaccines in the nineteenth century claimed that "the smallpox vaccine turned children into cows", today the claims are more "sophisticated", but just as wrong.

As we move further away in time from the diseases that vaccines have protected us against, it is possible to forget that just because the victims of infectious diseases are not around to "tell their stories" it should not make those horrors any less real.

Finally, I want to highlight two aspects of the anti-vaccine fight. The first is the human consequences of letting people go unvaccinated.

A seventeen-year old unvaccinated girl picked up measles on a trip to Romania, returned to the United States, and ended up infecting close to 500 people in a couple of weeks. 31 of the 35 people who had never received the measles vaccine ended up becoming infected. "Of the remaining 465 people, only 3 (0.6 percent) were infected. The girl ... had managed to infect almost every person susceptible to the disease."
"In 1937, Edward Whitney, a widowed insurance salesman, left his ten-year-old daughter, Aubrey, in the care of her aunt in Chicago. Aubrey was a diabetic. The aunt, a Christian Scientist, took Aubrey to her practitioner, William Rubert, who immediately took her off insulin. On December 10, 1937, Aubrey Whitney died in a diabetic coma; Rubert wasn't held accountable for her death. Twenty-two years later, Edward Whitney walked into Rubert's office, pulled out a 32-caliber handgun, and shot him at point-blank range."

"On March 9, 1984, Shauntay Walker died of bacterial meningitis. Her mother, Laurie, a Christian Scientist, had kept her home for seventeen days. At the time of death, Shauntay, who was five years old, weighed only twenty-nine pounds. In 1990, Walker was convicted of manslaughter, but the conviction was overturned with the help of her lawyer, Warren Christopher, who would later become Bill Clinton's secretary of state."
And let me end this long, very long review, by reproducing from the book the horrors of the infectious diseases that vaccinations have eliminated, or all but eliminated, and which the anti-vaccine crusade threatens to let loose upon the world once again.

Smallpox, for instance, would "start benignly with fever, headache, nausea, and backache"
"The symptoms that would follow, however, were unmistakable. The face, trunk, and limbs erupted in pus-filled blisters that smelled like rotting flesh—blisters so painful that victims felt like their skin was on fire. Worse: smallpox was highly contagious, spread easily by coughing, sneezing, or even talking. As a consequence, smallpox infected almost everyone. Pregnant women suffered miscarriages, young children had stunted growth, many were permanently blinded, and all were left with horribly disfiguring scars. One in three victims died from the disease."
"Smallpox killed more people than the Black Death and all the wars of the twentieth century combined; about five hundred million people died from the disease.
When European settlers brought smallpox to North America, they reduced the native population of seventy million to six hundred thousand."

"In the early 1900s, children routinely suffered and died from diseases now easily prevented by vaccines. Americans could expect that every year diphtheria would kill twelve thousand people, mostly young children; rubella (German measles) would cause as many as twenty thousand babies to be born blind, deaf, or mentally disabled; polio would permanently paralyze fifteen thousand children and kill a thousand; and mumps would be a common cause of deafness."
"Before the vaccine, every year pneumococcus caused four million ear infections, one hundred and twenty thousand cases of pneumonia requiring hospitalization, thirty thousand bloodstream infections, and twenty-five hundred cases of meningitis."

"On August 31, 1998, the FDA licensed a vaccine that protected against a common intestinal virus called rotavirus. Rotaviruses, which cause fever, vomiting, and diarrhea in infants and young children, are responsible for nine hundred thousand office visits, seventy thousand hospitalizations, and sixty deaths every year in the United States, mostly from dehydration. In the developing world, rotavirus is a more prodigious killer, causing the deaths of two thousand children every day. Because the disease is common and occasionally fatal, the CDC recommended the vaccine for all infants."

"Before the vaccine, measles infected as many as four million American children, causing a hundred thousand to be hospitalized and five hundred to die every year."

"Before a vaccine was first used in the United States in the 1940s, about three hundred thousand cases of whooping cough caused seven thousand deaths every year, almost all in young children. Now, because of the pertussis vaccine, fewer than thirty children die every year from the disease."
"The bacterium that causes whooping cough, Bordetella pertussis, triggers the accumulation of thick, sticky mucus in the windpipe. Children try to rid themselves of the mucus by coughing; but it's so gummy and tenacious that it's impossible to cough up. Panicking, a child coughs and coughs—as many as twenty times in a row—without breathing in. Because these coughing spells deprive children of oxygen, many cough until they're literally blue in the face. The long-awaited breath, taken against a narrowed windpipe, creates an unmistakable high-pitched sound. Parents who hear the whoop of whooping cough never forget it. Coughing isn't the only problem. Some children with whooping cough suffer pneumonia when pertussis bacteria travel to their lungs, or seizures when their brains don't get enough oxygen, or suffocation when mucus completely blocks their windpipes. Some cough so hard that they break ribs or so long that they become malnourished."
"But one disease caused by Hib is even more frightening—a disease that most parents have never heard of and most young doctors have never seen: epiglottitis
The epiglottis is a thumb-like wedge of tissue at the back of the throat; when people swallow, it flops down over the windpipe, preventing food and water from entering the lungs. Hib is unique among bacteria in its capacity to infect the epiglottis. Once infected, the epiglottis can block the windpipe—no different, in a sense, than being smothered by a pillow."
It is these diseases that the anti-vaccine brigade seeks to return children to. Shame on them.
Book Details:
ISBN: 9780465023561, 9780465029624, 0465029620, 0465021492
Author: Paul Offit (@DrPaulOffit)
Publisher: Basic Books
Pages: 270 (paperback)

Kindle Excerpt:

© 2012, Abhinav Agarwal (अभिनव अग्रवाल). All rights reserved.