Thursday, June 19, 2008

EP Has Done It Again

Today's Empowered Patient on 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.


Anonymous said...

So, can you publish this so that there's a rebuttal to her article? Not vaccinating your kids is just crazy.

Tiny Shrink said...

I wish.

Bardiac said...

I think vaccines are probably the most amazing medical advance short of potable water. (I'm a big fan of potable water, too.)

But I do have a question. I went to the doctor a few years back after not having gone for [cough] quite some time. And I didn't know if I'd ever had chickenpox. So they ran a titer, and said come and get the chickenpox vaccine, and I did.

Later, I asked my Mom and she said I'd had a nasty case of chickenpox as a toddler. So I guess the immunity wears off?

Anyway, the real question: the chickenpox vaccine uses live virus, no? And the same virus causes shingles? So is there a chance that one could (much later, of course) get shingles from exposure via the virus? (I'm wondering since even if you had chickenpox and have a full immune response some virus can hang out and do the shingles thing decades later? I don't have shingles, and if I get it, I'll blame it on the childhood illness, but I'm still curious.)

Sweet Mama said...

Thimerisol hasn't been removed from vaccines, it is still there in undefined 'trace amounts'. Why can't a medical student read a package insert??? Honestly when doctors get basic facts like this wrong, I have trouble respecting the profession as a whole.

The scientifically correct statement would be that the amount of thimerisol in vaccines has been LOWERED.

And FYI, as a future medical professional, I speak to mothers about vaccinations all day. We have many concerns and objections. They include: Thimerisol, Aluminium, Formaldehyde, Anti-freeze (forget chemical name here), pushing childhood diseases into older populations, the agressive schedule, combining too many diseases at once, temporarily compromised immunity after each round of shots, under-reported side effects and severe reactions and the downplaying of these by the medical establishment (my biggest fear personally is that my child would have a reaction and NO ONE would believe me), the fact that new vaccines don't have a long history by which to judge safety over time, the fact that vaccine history is peppered with 'oops' type incidents (OPV causing Paralytic Polio, for example) etc. etc.

All scientifically valid concerns founded in fact.

The idea that we object to the number of 'pokes' is so condescending! Of course a poke is not a big deal!!! It is temporary and fleeting and a small price to pay, unlike a severe reaction, which is a huge price to pay. The idea that parent's chief objection is to multiple pokes paints us as simpleminded nincompoops/commoners and I believe it is SOLEY circulated to justify the new combo vaxes, because I have never heard it from a real live mother.

As a future doctor, I just really hope you will develop more respect for parents and also more respect for the concept of true informed consent.

Tiny Shrink said...

Bardiac- the same thing happened to me. I have pictures to prove I had chicken pox as a kid, but my titers were low and to get into med school I had to get the shot. You are correct that the vaccine contains virus, and that shingles is caused by re-activated virus in the nerves. However, it is unclear whether the vaccine will cause more or less shingles. They even use roughly the same vaccine in elderly patients to prevent shingles. There is speculation that vaccinating more children may cause less shingles later, but I think it's hard to say.

Tiny Shrink said...

Sweet Mama- Take a deep breath and calm down. I think you read over the part where I said I had concerns about how many shots we give at a time. I also think you skipped the part where I said I had well-educated friends who are concerned about vaccines despite knowing better. It's natural to have concerns when your kids are involved.

Thimerosal: go to the fda website here:
You're right, I was unclear. I knew that there is still thimerosal in a three of the flu shots, and apparently one form of DTaP still has a trace. You can look up their definition of 'trace', it's hardly undefined (it's less than 1 microgram per dose). I was inaccurate, and I apologize. I was thinking about MMR when I wrote that. The same website does not make any mention of ethylene glycol, or formaldehyde. 2-phenoxyethanol is not the same thing as ethylene glycol. I did find formaldehyde here: as a part of making the vaccine Infanrix (DTaP).

I digress. I cannot find data to suggest that immunity is decreased post-vaccination. I'm still looking, but I'd imagine most of the studies I'd need are too old to be found online on Pubmed (and I've lost my library access prior to starting residency).

I entirely agree with you about not having long enough follow-up data on some vaccines. It's why I'm not a big fan of mandating HPV vaccination, no matter how much Merck pays Rick Perry. In fact, so long as you can discuss these issues with these parents in a rational manner, I'd say they're all legitimate concerns. I do worry, though, that someone coming in saying "There's anti-freeze in that vaccine!" isn't getting their information from a very scientific source and probably won't be open to discussion about it.

As to the "number of pokes" argument, I guess you never worked in the clinics I worked in. I had numerous mothers complain about the number of shots and several tried to leave with their kids rather than subject them to so many pokes. Of course, at this same clinic I had a mother refuse the HPV vaccine "because it makes the girls sterile." No amount of discussion could make her believe otherwise. So, perhaps the education level at this clinic was different than at yours?

And finally, if you think I'm the kind of doctor who is going to thrust a medicine or shot at a patient and say "here, take this" without any informed consent and not try to answer their questions (and accept their refusal, should they choose) then you obviously haven't read any of my blog, but are only here to troll because you googled "vaccine safety" or somesuch and were directed to this blog. I hope that is not the case.

Thanks for the opportunity to do a little more background research. I stand by my initial conclusion, that the CNN article does nothing to allay fears about vaccines and does promote junk science. I'll add a note about the thimerosal.

Bardiac said...

Wow, thanks for answering! It's really interesting, isn't it, the way the scientific folks figure out the immunology and such! Thanks :)

I wonder what the differences are with the shingles vaccine?

Barbie said...

WHAT!!! I was not informed of the thimerosal content in the DTaP I just got! I'm gonna get autism now. My poor beautiful brain...

Chris Hickie, MD said...

tiny shrink-

Thank you for being a bright beacon in a sea of muddled garbage spread by ignorant reporters and dopes such as Dr. Sears.

Let's see if Sears has the guts to apologize to all his "informed" parents as their children catch the vaccine preventable diseases he's helping to let back in the US, such as measles to start with.

BTW thank you for straightening out that poster who thought there was still mercury in all vaccines.