EP Has Done It Again

Today's Empowered Patient on CNN.com has really "chapped my hide" (as an old salsa commercial used to say). Today, she has gone for the vaccines. She even titles the article with a question: "Should I Vaccinate My Baby?" LIKE IT'S REALLY AN OPTION!

Ahem. Must... not... throttle... aweraerfd... must try to write rationally...

Okay, so here's what I think of her article: it sucks. It teeters on the edge of inflammatory journalism to bring bad information to worried parents. AND, she never actually answers the question she poses in the title.

As always, we start off with a story. The worried parent who wants to change up the vaccine schedule for her kiddoes, even though her first child received them all on time and was fine. Did you read that right? Yes, her first child was fine, and didn't die of measles and wasn't crippled by polio. Yet, she decided she wanted to change it up for kids #2 and #3.

Then, a quote from the enemy: the doctor. He says he'll work with a parent to change up a vaccine schedule, even if he disagrees. He then says "I share with them what I know, but ultimately, it's the parent's decision." In other words, he shares the science of vaccines with them, and they still choose to go against. Sadly, this is not the point Ms. Cohen is trying to make.

Then, she lists five changes that some pediatricians and families might be making (right now!) to the vaccine schedule. She even specifically says she is not going to address the pros and cons to each approach, or touch the autism/vaccine debate. In other words, this is what people are doing, but we have no idea why.

#1. "Delaying the first hepatitis B shot". Since the first Hep B is given prior to discharge from the hospital, some doctors find this ludicrous, as babies aren't having unprotected sex or injecting drugs, so they'll delay this shot till the baby is two months old. Since, according to the CDC vaccine schedule, the child is supposed to receive the second Hep B at 2 months, I'm not sure when they'll then receive dose 2.

Also, kids who are household contacts of people infected with Hep B are also at risk. Just because mom didn't have it doesn't mean someone else couldn't. I'm really not opposed to Hep B at birth.

#2. "Not doing some shots at all". Since some diseases aren't as scary as others, some parents opt out of certain shots. The parent interviewed in the article opted out of the rotavirus vaccine and the chicken pox vaccine. Now, I've heard the argument for skipping the chicken pox vaccine before--"well, I had it, and I was fine." True. I had chicken pox at 3 years old and I did fine. However, there are currently several problems with this scheme. First, it's harder to find kids who have the chicken pox in order to get your kid exposed to get it. Therefore, your kid is going to be older when they get it, and the older you are the sicker you get with Varicella. Second, Varicella is a required vaccine for school now, so if your kid didn't get this shot you're going to have to go through the vaccine exemption form.

As far as rotavirus goes, it's a brand new vaccine and a lot of kids end up missing it anyway (at least in the clinic I was in), because it has to be given at 2, 4, and 6 months. There is no catch-up for that vaccine, so if you miss it, it's done. In the United States, infectious diarrhea is not a leading cause of infant mortality, so I guess this one is really up to you.

#3. "Checking for 'titers' before giving booster shots". First off, I like how 'titers' gets quotation marks. It's like they're not even real! Sorry. So now she suggests that you can get titers drawn before booster shots to see if the booster is necessary. She does at least have the decency to add that this procedure will not be covered by the majority of insurance, so if you want this you'll pay out of pocket (depending on how many titers you want, this might be over $100 or so--I couldn't find an accurate price online.) I don't think there's anything wrong with this approach, so long as you use it appropriately. Just remember, though, for those parents whose main objection to vaccines is the number of pokes for your kid: it's a lot easier to give a tiny little shot than it is to draw blood from a baby. I'm just sayin'.

#4. "Spreading the vaccines out over a longer period of time". Here's where it gets funny again. She provides a link to the Sears Schedule, "an alternative vaccine schedule developed by pediatrician Dr. Robert Sears. Sears' patients bring their babies in for shots seven times between the ages of 2 to 9 months, never receiving more than two shots at each visit." Unfortunately, if you click on her link, it takes you to an ad on Sears' website for his book on vaccines. If you want all his magic information on what's really in your vaccines, and how to spread them out, you have to buy his book (it's only $11.19, come on!). I've looked up on Pubmed "Sears vaccine schedule" and the answer was "No items found." Nor does Robert Sears appear to be a published author on PubMed. Neither Cohen nor Sears gives a really convincing argument for stretching the vaccines out like this, although I'm sure Sears' business manager likes getting kids in 7 times instead of just 3, as they can bill for each visit (at least as a nurse visit). Note that if your kid is on most Medicaid plans, this will not work, as you get visits at 2, 4, and 6 months or when the child is sick. That's it.

#5. "Splitting up combined shots". I reread this section several times and I cannot find any reason behind why you would want to do this. Sears' website states that some of the combo vaccines have a less favorable ingredient profile, but to find out why you'll have to buy his book. (one more bitch about Sears' website: below this is a link to "Find a vaccine-friendly doctor near you." Um, I'm sorry, isn't every doctor who gives vaccines "vaccine-friendly"? Oh, I'm sorry, you must have meant "vaccine-suspicious" doctor, like you.)

She concludes the article with "another consideration: what's best for your child." Now, she tells the story of Hannah Poling, the child whose autism was found to have been exacerbated by her childhood vaccines by the "vaccine court." Here's a review article in NEJM, but watch out--the author holds the patent on Rotateq, the rotavirus vaccine. Apparently, Hannah Poling had a rare mitochrondrial disorder and had been susceptible to infection prior to receiving the shots.

By throwing in this anecdote, and then getting a pediatrics professor to endorse recommending a change in vaccine schedule for any family history of autistic spectrum disorders, now Cohen has added credence to this faulty theory. Of course, if Poling received those five shots at 19 months old, she was way behind the schedule anyway (why?) and probably shouldn't have received at least a few of the shots she was given--she was too old. (Not that I think that's what caused her problem, but still--something else was not right here).

So, there we have it. The Empowered Patient strikes again, telling nervous parents that doctors don't know what we're doing, that it's a fight between us for your health (and now your child's health), and that making unproven changes in the vaccine schedule are fine. Good job! So when the next round of children goes unvaccinated, and gets measles or polio, or has necrotic varicella, I think we should send them to Ms. Cohen's house--she clearly knows more than we doctors do, anyway.

*** I will go on the record here to say that I'm not at all concerned about vaccines and autism. I've seen the data, over and over again. It's not the vaccine MMR itself, OR the thimerosal (which has been removed*). That said, I know perfectly intelligent people who have become parents and start worrying about this. Of course they do, it's their kid! I'm not making light of people who worry about this. I think vaccines are great, but I do have concerns about how many we give at a time. However, without seeing any evidence that it's causing health problems, that's all they are--my concerns. Of course, if you'll pay me $11 for a book, perhaps I'll write a book of junk science, too, and then we'll both be happy.***

*I meant that the thimerosal has been removed from MMR (in 2001). It's true that 2 influenza vaccines contain measurable (though small) amounts, 1 contains trace, and 1 DTaP vaccine contains trace (<1 microgram per dose. There are 2 flu shots without thimerosal: FluZone and Flumist [nasal]). If you are still concerned about thimerosal, here's one study to check out: JAMA 2003 Oct 1;290(13):1763-6, which showed no difference between children who got thimerosal-containing versus thimerosal-free vaccines (in terms of ASD), AND failed to show a dose-response relationship between thimerosal and ASD. That said, I'm not opposed to removing it from vaccines, so long as you can find a suitable means of keeping the vaccine bacteria-free for injection. Thanks to Sweet Mama for the correction.