Hello Everybody!
Whew...what in the world happened to April!?! Did someone accidentally hit the fast-forward button? Some get their foot off the gas pedal and slow things down a bit, please!! I am just not quite ready for summer...yesh!
Today Autism in on the table. I always believed it was all those crazy pregnant women that wouldn't give up their coffee that caused autism. I never believed that faker that said it was vaccinations, boy was that a fiasco! Any way here some more information to keep you in the know.
Until next time my knowledge gourmets,
The Chef
To Vaccinate or Not: Calming Worried Parents
Arthur L. Caplan, PhD; Paul A. Offit, MD
Close Up With Paul Offit
Arthur L. Caplan, PhD: Welcome
to Close-Up With Art Caplan. I am very excited today to have as my
guest Dr. Paul Offit, Head of Infectious Diseases at the Children's
Hospital of Philadelphia. Thank you so much for coming.
Paul A. Offit, MD: Thank you, Art.
Dr. Caplan: It's
fair to say that, in my view, Paul is the leading advocate and has done
more for promoting vaccination than anybody else I know in the world.
He has been a staunch advocate of helping kids receive necessary
vaccines and has been a pioneer himself in vaccine research.
Calming a Parent's Vaccine Fears
Dr. Caplan: In
your experience, what can be done to calm parents who are worried and
hear such things as, "My child got sick after a vaccination"? Putting
aside the lack of merit behind some of those fears, how do you calm a
parent down?
Dr. Offit: A fear was raised originally in
the late 1990s and early 2000s that vaccines caused autism. Fair enough.
From the parent standpoint, my child was fine, he or she got a vaccine,
and now my child is showing signs and symptoms consistent with autism.
Could vaccines have done it?
The good news is that this is an
answerable question. It has been answered in a scientific venue. Tens of
millions of dollars have been spent by public health and academic
professionals to try and answer this question: If you receive a vaccine,
are you at greater risk for autism than if you don't receive a vaccine?
Now we can comfortably say to parents that those 2 things are not
causally associated. Vaccines don't cause autism.
Dr. Caplan: So we have a mountain of evidence?
Dr. Offit: Yes.
The problem isn't that parents have the questions. It's fair that they
have the questions. Nor is the problem that people haven't responded
with millions of dollars to answer the question. They have answered the
question. So, what now? Why, with all that information on hand, can't we
convince people?
I don't think it's a lot of people, but some
people simply have the fear, and it's hard to make the fear go away. In
part, it is because we haven't identified a clear cause or causes for
autism. We don't have a definitive cure for autism, so that keeps the
fear running.
Consider diabetes in the 1800s, when people didn't
know what caused it. There were many thoughts about what caused it, and
many thoughts about what could cure it. When Banting and Best discovered
insulin and we knew the cause of diabetes, and how to cure it, all of
the myths disappeared. For something like autism, that may be what it's
going to take.
Dr. Caplan: Do you think that it would help
to say to a parent that there are suggestions that older parents are
more likely to have a child with autism, or that environmental toxins
might be associated with autism? I have seen these things explored as
causes of autism. Would it calm their fears to say that there may be
other factors that we are chasing besides vaccines as causes of autism?
Dr. Offit: You
can certainly say that, with respect to environmental factors, vaccines
are clearly the best studied, and many factors have been looked at in
autism research that make sense and are confluent. Clearly, there is a
genetic predisposition for autism. If you look at the proteins that
those genes make -- the so-called developmental proteins -- they are
often expressed in the first or early second trimester. Environmental
factors, such as valproic acid, thalidomide, or rubella virus, increase
the risk for autism because they affect the child in utero.
Eric Courchesne and colleagues
[1]
at the University of California, San Diego, showed that there are
folding abnormalities in the brain. You can actually see the foldings in
utero by looking at the child's brain, so it's all consistent.
When you have autism, you are born with autism. There is no changing that, and to some people, that is helpful to know.
Responding to "That's Too Many Vaccines"
Dr. Caplan: What about parents who are worried about their child receiving too many vaccines at once? How do we handle that concern?
Dr. Offit: I
don't care how sophisticated you are about virology or microbiology or
immunology -- when you watch your child lie down on that white paper and
receive as many as 5 injections at once, it looks like it's too much.
When
you are in the womb, you are in a sterile environment. When you enter
the birth canal and the world, you are not, and very quickly there are
trillions of bacteria on the surface of your body. I'm not trying to
sound like Carl Sagan, but you have about 100,000 trillion (10
14)
bacteria on the surface of your body. You actually have more bacteria
on the surface of your body than the number of cells in your body.
We
have a way of carrying bacteria from one place to the next, and to
which you make an immune response. Adults typically make as much as 5 g
of secretory immunoglobulin A and immunoglobulin G daily to make sure
that those bacteria stay at the mucosal surface.
One
single bacterium out of the trillions of bacteria on your mucosal
surfaces has between 2000 and 6000 immunologic components. If you add up
all of the immunologic components in vaccines that are given in the
first few years of life, it comes to about 160. It's literally a drop in
the ocean of what you encounter and manage everyday, but you don't see
that.
Dr. Caplan: When the parent comes in and says, "I'm
worried about too many vaccines," and then goes home and lets the child
crawl on the floor or lets the dog lick the child, is that worth
pointing out to them? They are not exposed only to what is there
naturally, but they are exposed to lots of agents in the ordinary course
of wandering around the house.
Dr. Offit: And that is
good, because it educates the immune system away from this Th2 response
toward the so-called Th1 response. It makes you less likely to be
allergic as you get older. That actually helps, but if people really
want to scare themselves, they should take a cotton swab and swab the
inside of the child's nose, put it on a wet-mount microscope slide, and
look at it. If it's teeming with bacteria to which your child makes an
immune response, that's a greater challenge than what you ever receive
in a vaccine.
Dr. Caplan: So those metaphors could help.
Dr. Offit: I think so, yes.
A Lose/Lose Situation for Clinicians
Dr. Caplan: Here
is another issue. Many doctors and nurses have had people come in and
say, "I don't want to vaccinate." What can we do with them? Should we
say, "Stop coming here," or should we try to work with them? Should we
say, "We will stretch out the vaccine schedule"? What's your view about
that?
Dr. Offit: I feel
sorry for the private practicing clinician, my wife being one of them.
It's a lose/lose situation. On the one hand, the doctor can say, "I'm
going to do the best I can to give this child whatever vaccines I can,"
knowing that you are sending the child away less than fully vaccinated,
and knowing that this is going to be a progressively more dangerous
world where there is a greater incidence of measles, whooping cough, and
bacterial meningitis.
Dr. Caplan: We have had outbreaks of all those diseases in the past year.
Dr. Offit: Now,
you know you are practicing substandard care. You know you are putting
the child at risk, and so it's hard for doctors. But on the other hand,
they can say, "If I don't at least try and play it the parent's way,
where does the person go then? Do they just go to a chiropractor who is
perfectly willing to not vaccinate their children, or to another doctor
who is willing to give them no vaccines?"
I
have seen my wife progress through this, and she has gone 180° toward
the opposite view. She is far more passionate. She says, "Let me love
your child. Don't put me in a position where I have to practice
substandard care. Don't put me in a position where I'm sending your
child out into this world that is becoming progressively more dangerous,
where they can get pneumococcal disease or varicella and suffer that.
Don't put me in that position. It's like coming to me and saying, 'I
love my child, but I don't trust car seats.'"
Dr. Caplan: I like that "let me love your child" angle. It
makes an alliance with the parents. What about when a child who hasn't
been vaccinated comes to the clinic? Do you say, "Don't mix with the
other patients in the waiting room"?
Do Parents Have a Responsibility to Others?
Dr. Offit: That's a good question: Do you have a responsibility to the waiting room?
In
the measles outbreak in San Diego that occurred a few years ago, that
is exactly what happened. The mother didn't vaccinate her children, and
she took her children to Switzerland. The 7-year-old got measles, came
back, and was sitting in the waiting room. The mother didn't know what
it was. She had never seen measles before.
The
child had fever and a rash, and was exposing everybody else in the
waiting room. Three of the children in the waiting room were less than 1
year of age and hadn't yet been vaccinated. All were severely infected
with measles, were admitted to the hospital, and one almost died. The
mother of the child who almost died said, "She made a decision for me."
Did she have a right to make that decision?
Dr. Caplan: Ethically,
it may be important to let people know you vaccinate not only to
protect your own child, but also to protect your neighbor, and I don't
think people understand that clearly. Sometimes it seems that it is all
self-interest.
Dr. Offit: Do we have a responsibility to
our neighbor? Is it our inalienable right to catch and transmit a
potentially fatal infection? I would like to think that the answer is
no.
Dr. Caplan: Pushing
that a little further, there have been movements in several states --
Rhode Island, for example -- mandating flu vaccines for pre-kindergarten
and daycare, saying that children can't go to these places unless they
are vaccinated. I think it includes the teachers now as well. Is this a
good idea? Should we push harder for that kind of requirement?
Dr. Offit: You
are seeing what has happened. Before the 1970s, there were medical
exemptions to vaccination, but no philosophical or religious exemptions.
Those were established in the 1970s and 1980s, so now 41 states have
religious exemptions, and 20 states have philosophical exemptions to
vaccines.
Dr. Caplan: "Philosophical" just means "I don't like it."
Dr. Offit: I'm not sure. It never made much sense to me.
Dr. Caplan: As a philosopher, it seems to me it is a deep philosophical objection.
Dr. Offit: Philo means love, and
sophia means wisdom. Where is the wisdom that says not getting a vaccine is better than getting one?
We
are seeing the consequences of those exemptions. When we see such
outbreaks as measles or whooping cough, invariably they are centered on
groups of people who have chosen to not vaccinate their children. Not
only do they serve as a reservoir for the children to become infected,
but they infect members of the surrounding community, so now we are
starting to see pushback. There was an article in
JAMA Pediatrics[2] on this topic, and we are seeing legislation not for expanding those exemptions, but for contracting them.
Dr. Caplan: It
seems to me that it still can be respectful of somebody's right to
choose if you say you have to watch a video program about vaccines or
certify that your doctor discussed the risks and benefits with you. I
don't think those requirements are too intrusive into somebody's
liberty.
Dr. Offit: My problem is this: Is it your right
to choose to put your child at risk and those who are going to come in
contact with your child? On the one hand, we are trained as physicians
to be open to all attitudes and beliefs. On the other hand, we watch
children come into our hospitals. Every year, at least 1 will die of an
infectious disease, and when you watch that happen -- when you watch a
child get flu, for example, and come into the hospital initially on
face-mask oxygen, and go onto a ventilator, and then an oscillator, and
then a heart/lung machine, and then die -- you see those parents slowly
watch their child fall off a cliff. When another parent comes to you a
week later and says, "I don't want to give my child a flu vaccine," it's
very hard to be passionate and say, "It's your right to choose." I just
don't feel that way.
Expand Vaccines for Pregnant Women
Dr. Caplan: We
have spent a lot of time trying to figure out how to manage resistance,
fears, and doubts. Where are we going? What is coming down the line?
Are we going to continue to give vaccines through needles? Are we going
to have the same array of vaccines, or are new ones imminent? What does
the future hold with respect to vaccination?
Dr. Offit: I
predict that the next great platform will be the pregnancy platform.
You are already seeing it to some extent. We now give the whooping cough
vaccine in the third trimester of pregnancy to try and prevent the
deaths of 20-30 children every year from whooping cough, all of whom are
less than 2 months of age. That is the only way to prevent that.
Dr. Caplan: And they die because they don't have any immunity to it?
Dr. Offit: That's
right. They are too young to have developed an active immune response,
and too young to be vaccinated. The first vaccine is given at 2 months
of age, so that is why we give pregnant women a pertussis vaccine. We
give the flu vaccine primarily to protect the mother who is pregnant and
who has a 7-fold increased risk of developing pneumonia and dying of it
than if she was not pregnant. We could have a meningococcal vaccine in
pregnancy to avoid the need for the meningococcal vaccine that is given
in the first year of life. I would like to think that down the line, we
will have a respiratory syncytial virus vaccine that is given during
pregnancy.
Dr. Caplan: Those are disorders that people often mistake for the flu.
Dr. Offit: Another
disease is group B streptococcus. All of those would be reasonable
vaccines to give to pregnant women, and they would benefit the newborns.
Dr. Caplan: There
is more to be said here, but hopefully we have provided some useful
information, solid tips, and maybe even some management strategies to
those in the field who are trying to engage vaccination.
Thank you
for all of the work you have done to promote vaccination and grapple
with these questions in public. You have been a great example to
physicians who say to me often, how do I engage? What do I do? You
write, you speak, you go toe-to-toe with critics on national television
or at a local high school assembly. You have shown a clear-cut path as
to how that should be done.
