Today’s guest post was submitted by Laila Tomsovic, ND.
Measles has arrived in western Massachusetts. I live and work in this educated, liberal community with high rates of vaccine refusal. I used to teach a class on childhood immunizations for new and expecting parents, so I’ve been asked to write out my thoughts on this recent outbreak and on the MMR vaccine specifically.
Vaccines have become a highly sensitive and controversial topic—at least in public discourse. The scientific and medical communities are pretty much on the same page. Nevertheless, both the pro- and anti-vax camps continue angry finger pointing and character assassination. Both sides are so dug in that no one is listening; it is frustrating and counterproductive.
Yes, I said both sides. This is a potentially controversial statement. The media tends to represent two sides of scientific arguments, even when the scientific community is generally in agreement. This representation creates a false sense of ongoing debate where there really isn’t one (at least not much). The scientific evidence that we have supports the safety and efficacy of the vaccine program. The decline of the national vaccine program would be a terrible thing for all of us. Herd immunity really does protect us.
However, there is a growing population of parents who are skeptical about vaccinating their children. These are well-intentioned people who are trying to make the best decisions for their children. Belittling them and calling them names does nothing to increase the rates of vaccination. And while the most radical vaccine opponents fueling this fire often misrepresent the evidence, it would be disingenuous to assert that the safety data on vaccines is complete. The evidence is not as complete as it should be. I have wondered whether self-censorship among researchers regarding adverse reactions is hindering vaccine safety research. The few who report findings of unexpected adverse reactions are maligned from all sides. Of course, it could be that the vast majority of scientists think this question has been answered. But still, there is a vehemence in these attacks that I have not come across in other fields.
In the periodic workshops I offered on this topic, I’ve found the most effective way to reach parents who are concerned about vaccine safety is to acknowledge that, like any medical intervention, vaccines have risks. I believe that authentic inquiry and honest discussion do more for the public’s trust than across-the-board denial. And that is what I hope to accomplish with the rest of this article where I will give some background on the measles virus, discuss the safety profile of the measles vaccine, and offer some other useful information for parents on the fence.
Measles is a highly contagious virus transmitted like the common cold i.e. via respiratory droplets. It is so contagious that you can catch measles by entering a room that a contagious person had left two hours before. Most of the time, the illness is fairly mild. But rare infections can be severe and even fatal—and it is not simple to predict who will have it easy and who will really suffer. Since 1995, there has been an average of one measles-related death per year in the U.S. Young children and adults are at the highest risk for serious complications. This is part of why vaccination is scheduled to start early: to protect the most vulnerable. However, measles is not one of the earliest vaccines recommended by the CDC schedule, because it is not as effective when given before 12 months of age.
Some anti-vaccine activists say that improved sanitation and nutrition took care of infectious disease before the vaccines came around. Clean water and sewers certainly did impact the incidence of infectious disease. Regarding measles specifically, improved nutrition was a major factor in dropping the death rate (more so than the incidence of disease). This link shows rates of both disease and death in Britain; notice the big drop in deaths from measles well before the introduction of the vaccine in the 1960s. However, by mid-century, the rates had basically plateaued. Then the vaccine was introduced and drastically dropped the incidence of disease, and consequently deaths as well. From the CDC’s Pink Book:
“Before 1963 approximately 500,000 cases and 500 deaths were reported annually, with epidemic cycles every 2–3 years. However, the actual number of cases was estimated at 3–4 million annually. Following licensure of vaccine in 1963, the incidence of measles decreased by more than 98%, and 2–3-year epidemic cycles no longer occurred.”
Keep in mind, there are other complications from measles infection besides death. For more detail the history of measles and the measles vaccine, you might read Dr. Ian York’s interesting “Measles week” series.
While we are on the topic of sanitation, I’d like to mention that every intervention carries some risk. Do you remember when walking down a city street meant risking a pot of raw sewage being dumped on your head? Neither do I. While I have no interest in going back, I want to point out that even sanitation is a double-edged sword. Before clean water and sewers were commonplace, polio was endemic, meaning always present in some part of the population. However, infection in infants less than 6 months was rare and/or they were asymptomatic. After sanitation measures were rolled out, kids were not exposed to polio at such a young age, leading to decreased immunity and subsequently the polio epidemics of the 1940s and 1950s.
All right, let’s talk about the vaccine. M-M-R® II is an effective vaccine. One dose works in 95-98% of kids, increasing to more than 99% after the booster dose. It is a live-virus vaccine that produces a mild, usually asymptomatic, non-communicable infection. Vaccine-induced immunity appears to be long-term and probably lifelong.
Vaccination may have had an impact on measles immunity and susceptibility in infants as well, even though children do not receive the vaccine until they are 12-15 months of age. Here is how that works: mothers, who develop a measles infection, develop a robust immune response. These antibodies are passed on to their infants and protect the babies in their first months of life. In moms who were vaccinated, fewer antibodies against measles cross the placenta to baby. This results in infants who are susceptible at a younger age than in the past. This is certainly a downside of immunization. The up side is that more of these babies survive to become parents than in days when wild-type measles was common.
BUT IS MMR SAFE??
“Because vaccines are so widely used—and because state laws require that children be vaccinated to enter daycare and school, in part to protect others—immunization safety concerns should be vigorously pursued in order to restore this trust.” IOM, 2002
As I mentioned earlier, all medical interventions have risks. MMR does have some of the more worrisome adverse effects of the vaccines we have. Some of the common ones associated with MMR include fever, rash, swelling of the lymph nodes, and inflammation of the parotid salivary gland. But these are also associated with catching the three viruses found in M-M-R® II naturally and occur less frequently with vaccination than infection. (Remember, MMR is a live virus vaccine and so induces a very mild, non-communicable infection.) Adult women, however, are at an increased risk for adverse effects of vaccination. Up to 25% may develop joint pain that can be either transient or longer lasting.
There are people who should not get a live virus vaccine like MMR, including those with severe immune suppression. It is important to know that women who are pregnant should not receive this vaccine and all women should avoid becoming pregnant for 3 months after receiving it. Additionally, the ProQuad vaccine, that includes varicella (chickenpox) along with measles, mumps and rubella, is not recommended for breastfeeding mothers, as the varicella virus may be transmitted through breast milk.
It was Andrew Wakefield’s 1998 Lancet study that started the big commotion over MMR, linking it with autism. The paper was fraudulent and has since been retracted. There are people who do not believe that Wakefield’s trial was fair and perhaps Brian Deer and the BMJ had gone after him with too much hype and vengeance. But to be honest, it doesn’t matter. I’ve read this short paper a number of times. Even if it was strictly factual and their methods were transparent (which they were not), the evidence he presented was too weak to draw any conclusions. His data does not link MMR vaccination with autism, but the media—very much encouraged by Wakefield—did. Really, it is a bad study. I don’t want to spend more time talking about autism and MMR, but if you want to learn more, check out the Yokohama study or this synopsis. I’m not an epidemiologist, but if you are, and are reading this, I’d love to hear your take on Wakefield’s response.
Autism aside, we do need more research into the safety of the measles vaccine. This was the conclusion of the highly respected Cochrane Collaboration in 2011. While they asserted that MMR is probably safe, they also admitted “the design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate.” Before you decide that is enough to stop vaccinating, know that the Cochrane investigators went on to say that the “existing evidence on the safety and effectiveness of MMR vaccine supports current policies of mass immunization aimed at global measles eradication.” So, this does not mean the vaccine is not safe. It does mean that we don’t know for sure what all the risks are. I would really like to see long-term studies on the impact of our childhood vaccination program on chronic disease. What might 30+ immunizations before the age of 6 contribute? We don’t currently know. Does this make me nervous? To be honest: a little bit, yes. But not enough to decline to vaccinate my children. Weighing the existing evidence on risks and benefits, vaccination emerges the better option.
“Because vaccines are so widely used—and because state laws require that children be vaccinated to enter daycare and school, in part to protect others—immunization safety concerns should be vigorously pursued in order to restore this trust.” iom, 2002
SHOULD YOU DELAY OR REFUSE THE MMR VACCINE?
Let’s start with what we know about delaying or refusing vaccines:
The bottom line and perhaps the most obvious consequence to alternative schedules is that they increase the amount of time an infant or young child is susceptible to a vaccine-preventable disease. This often (although not always) ends up being the time when a child is most at risk for severe infection. I’ve heard many parents say that because they raise healthy-eating and healthy-living children, they are safe. This is a falsehood.
Look, I’m a naturopathic doctor. Therapeutic lifestyle change (TLC!) is the foundation of my practice. Diet and lifestyle alone can create vibrant health (in some people). Certainly being healthy, without underlying chronic disease, makes it less likely you’ll fall ill and/or have terrible outcomes when you do. But measles is extremely contagious. A healthy lifestyle is no guarantee that you won’t catch it. Of course, immunization is not either, but the 95-99% reported by various reliable bodies is pretty darn good.
Are you ready to refuse?
From a civil liberties perspective, I believe that Americans should have the right to choose what happens to their bodies. But refusing vaccines is not a decision to be made lightly. It impacts you, your children, and your community. Parents should consider if their work and lifestyle would allow them to stay home with their sick children the entire time they are contagious (usually up to eight days). Parents should also consider that it is next to impossible to avoid exposing others in the event you or your child is infected with measles. The rash doesn’t appear for 2-4 days, and at the onset of symptoms, there are only general signs of illness like fever and runny nose. You are not likely to be thinking measles at this time but will be very contagious. Please don’t unintentionally delay vaccination out of indecision, misinformation or a lack of information.
I must admit, when I first started considering these issues, I was much more skeptical of vaccine safety. I hadn’t done much research; I hadn’t taken my pediatrics courses yet, but like many parents out there, I had gotten the message that there was something to be scared of. When I started intensively researching the issue for my local lectures, I suspected my audience would be of a similar persuasion. I did my best to look at the evidence beyond the arguments on both sides. It wasn’t easy to find legitimate evidence of major harm from vaccines beyond known adverse events. And what was out there kept being debunked. After years of reading, writing, and teaching on the topic, I have gotten progressively more and more convinced that the risk-benefit analysis favors immunization with MMR. Does safe equal risk-free? Of course not. But it’s the best protection we have from a virus that is on the rise, and even better in conjunction with healthy habits that support the foundation for health.