Evernote health link

Tuesday, June 3, 2008

a nicely balanced article on vaccines and the risks of not vaccinating

Wednesday, May. 21, 2008

How Safe Are Vaccines?

Correction Appended: May 29, 2008

Life, if you're a bacterium or virus, boils down to this: finding a pristine human home to provide for your every need, from food and nutrients to shelter against biological storms. As a microbial drifter, you can literally travel the world, hopping from host to host when the opportunity presents itself or when conditions at your temporary residence start heading south. There's no worry about taking along life's necessities either—viruses in particular are adept at traveling light; incapable of reproducing on their own, they think nothing of co-opting the reproductive machinery of their cellular sponsors to help them spawn generation after generation of freeloading progeny.

But ever since Edward Jenner, a country doctor in England, inoculated his son and a handful of other children against smallpox in 1796 by exposing them to cowpox pus, things have been tougher on humans' most unwelcome intruders. In the past century, vaccines against diphtheria, polio, pertussis, measles, mumps and rubella, not to mention the more recent additions of hepatitis B and chicken pox, have wired humans with powerful immune sentries to ward off uninvited invasions. And thanks to state laws requiring vaccinations for youngsters enrolling in kindergarten, the U.S. currently enjoys the highest immunization rate ever; 77% of children embarking on the first day of school are completely up to date on their recommended doses and most of the remaining children are missing just a few shots.

Yet simmering beneath these national numbers is a trend that's working in the microbes' favor—and against ours. Spurred by claims that vaccinations can be linked to autism, increasing numbers of parents are raising questions about whether vaccines, far from panaceas, are actually harmful to children. When the immune system of a baby or young child is just coming online, is it such a good idea to challenge it with antigens to so many bugs? Have the safety, efficacy and side effects of this flood of inoculations really been worked through? Just last month the U.S. government, which has always stood by the safety of vaccines, acknowledged that a 9-year-old Georgia girl with a preexisting cellular disease had been made worse by inoculations she had received as an infant, which "significantly aggravated" the condition, resulting in a brain disorder with autism-like symptoms.

Though the government stressed that the case was an exceptional one, it provided exactly the smoking gun that vaccine detractors had been looking for and vaccine proponents had been dreading. More and more, all this wrangling over risks and benefits is leading confused parents simply to opt out of vaccines altogether. Despite the rules requiring students to be vaccinated, doctors can issue waivers to kids whose compromised immune system might make vaccines risky. Additionally, all but two states allow waivers for children whose parents object to vaccines on religious grounds; 20 allow parents to opt out on philosophical grounds. Currently, nearly one-half of 1% of kids enrolled in school are unvaccinated under a medical waiver; 2% to 3% have a nonmedical one, and the numbers appear to be rising.

Parents of these unimmunized kids know that as long as nearly all the other children get their shots, there should not be enough pathogen around to sicken anyone. But that's a fragile shield. Infectious-disease bugs continue to travel the globe, always ready to launch the next big public-health threat. Pockets of intentionally unvaccinated children provide a perfect place for a disease to squat, leading to outbreaks that spread to other unprotected kids, infants and the elderly. Ongoing measles outbreaks in four states are centered in such communities; one originated with an unimmunized boy from San Diego who contracted the virus while traveling in Europe—where the bug was thriving among intentionally unimmunized people in Switzerland. Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC), says, "We are seeing more outbreaks that look different, concentrated among intentionally unimmunized people. I hope they are not the beginning of a worse trend."

If they are, it's possible that once rampant diseases such as measles, mumps and whooping cough will storm back, even in developed nations with robust public-health programs. That is forcing both policymakers and parents to wrestle with a dilemma that goes to the heart of democracy: whether the common welfare should trump the individual's right to choose. Parents torn between what's good for the world and what's good for their child will—no surprise—choose the child. But even then, they wonder if that means to opt for the vaccines and face the potential perils of errant chemistry or to decline the vaccines and face the dangers of the bugs. There is, as yet, no simple solution, but answers are emerging.

The Autism Riddle
More than any other issue, the question of autism has fueled the battle over vaccines. Since the 1980s, the number of vaccinations children receive has doubled, and in that same time, autism diagnoses have soared threefold. In 1998, British gastroenterologist Dr. Andrew Wakefield of London's Royal Free Hospital published a paper in the journal the Lancet in which he reported on a dozen young patients who were suffering from both autism-like developmental disorders and intestinal symptoms that included inflammation, pain and bloating. Eight of the kids began exhibiting signs of autism days after receiving the MMR vaccine against measles, mumps and rubella. While Wakefield and his co-authors were careful not to suggest that these cases proved a connection between vaccines and autism, they did imply, provocatively, that exposure to the measles virus could be a contributing factor to the children's autism. Wakefield later went on to speculate that virus from the vaccine led to inflammation in the gut that affected the brain development of the children.

Like the initial tremor that triggers a massive earthquake, Wakefield's theories resonated throughout the autism community, where vaccines had been regarded with suspicion for another reason as well. Ever since the 1930s, a mercury compound known as thimerosal had been included in some vaccines—though not the measles inoculation—as a preservative to keep them free of fungi and bacteria. Thimerosal can do serious damage to brain tissue, especially in children, whose brains are still developing. It was perhaps inevitable that parents would make a connection between the chemical and autism, since symptoms typically appear around age 2, by which time babies have already received a fair number of vaccines. That link could be merely temporal, of course; babies also get their first teeth after they get their first vaccines, but that doesn't mean one causes the other.

In 2001, however, a U.S. Food and Drug Administration study revealed that a 6-month-old receiving the recommended complement of childhood vaccinations was exposed to total levels of vaccine-based mercury twice as high as the amount the epa considers safe in a diet that includes fish. By the end of that year, thimerosal-free formulations of the five inoculations that included it—hepatitis B, diphtheria, tetanus and pertussis and some versions of Haemophilus influenzae type b (Hib)—had replaced the older versions. The result was a drop in mercury exposure in fully immunized 6-month-old babies from 187.5 micrograms to just trace amounts still found in some flu vaccines. Yet there's been no effect on autism rates. In the seven years since the cleaned-up vaccines were introduced, new cases of autism continue to climb, reaching a rate of 1 in every 150 8-year-olds today. That trend suggests that other factors, including heightened awareness of the condition and possible genetic anomalies or environmental exposures, are behind the climbing rates. What's more, in the decade since Wakefield's watershed paper, 10 of its 13 authors have retracted their hypothesis, admitting that the study did not produce solid enough evidence to support a connection between the measles virus in the MMR vaccine and autism.

But the damage had been done. Parents, already uneasy about immunizations, now felt betrayed by government health authorities and a vaccine industry that simply kept the shots coming, with today's kids receiving up to 28 injections for 14 diseases, more than double the number of shots required in the 1970s. "There is no doubt in my mind that my child's first cause of autism is the mercury in vaccines," says Ginny DeLeo, a New York science teacher whose son Evan, born in 1993, was developing normally until he was a year old. The day the boy received his fourth dose of Hib vaccine, DeLeo had to rush him to the hospital with tremors and a 104 deg F (40 deg C) fever, which later led to seizures. Evan recovered, and several months later he received the first of two MMR shots. Within months, he stopped talking, and autism was diagnosed.

So, is there a link? In 2003, a 15-person committee impaneled by the CDC and the National Institutes of Health analyzed the available studies on thimerosal and its possible connections to autism and concluded that there was no scientific evidence to support the link. In a further show of confidence, the committee noted that it did "not consider a significant investment in studies of the theoretical vaccine-autism connection to be useful." Instead, the panel recommended that studies focus on less explored genetic or biological explanations for the disease.

There is also little evidence to support the claim made by antivaccine activists that the battery of shots kids receive can damage the immune system rather than strengthen it. Experts stress that it's not the number of inoculations that matters but the number of immune-stimulating antigens—or proteins—in them. Thanks to a better understanding of which viral or bacterial proteins are best at activating the immune system, that number has plummeted. The original smallpox injection alone packed 200 different immune-alerting antigens in a single shot. Today there are only 150 antigens in all 15 or so shots babies get before they are 6 months old. "The notion that too many vaccines can overwhelm the immune system is just not based on good science," says Dr. Paul Offit, chief of infectious diseases at Children's Hospital in Philadelphia.

My Child, My Choice
If the push-back against vaccines were only about the science, doctors might have an easier time making their case. But there's more going on than that. Parents object to the mandatory nature of the shots—and the fact that their child's access to education hinges on compliance with the immunization regulations. There's also the simple reality that the illnesses kids are being inoculated against are rarely seen anymore. When diseases like polio ran free in the early 1900s, the clamor was less about why we needed vaccines than about why there weren't more of them. Once you've seen your neighbor's toddler become paralyzed, you're a lot more likely to worry that the same thing will happen to yours. "The fact is," says Offit, "young mothers today never grew up with the disease."

What worries him and others is that young mothers of tomorrow will—and that could be disastrous. CDC officials estimate that fully vaccinating all U.S. children born in a given year from birth to adolescence saves 33,000 lives, prevents 14 million infections and saves $10 billion in medical costs. Part of the reason is that the vaccinations protect not only the kids who receive the shots but also those who can't receive them—such as newborns and cancer patients with suppressed immune systems. These vulnerable folks depend on riding the so-called herd-immunity effect. The higher the immunization rate in any population, the less likely that a pathogen will penetrate the group and find a susceptible person inside. As immunization rates drop, that protection grows thinner. That's what happened in the current measles outbreaks in the western U.S., and that's what happened in Nigeria in 2001, when religious and political leaders convinced parents that polio vaccines were dangerous and their kids should not receive them. Over the next six years, not only did Nigerian infection rates increase 30-fold, but the disease also broke free and ranged out to 10 other countries, many of which had previously been polio-free.

As long ago as 1905, the U.S. Supreme Court recognized the power of the herd and ruled that states have the right to mandate immunizations, not for the individual's health but for the community's. That principle, say vaccine proponents, should still apply. "The decision to vaccinate is a decision for your child," says Dr. Jane Seward, deputy director of viral diseases at the CDC, "but also a decision for society."

Some parents have taken to cherry-picking vaccines, leaving out only the shots they believe their children don't need—such as those for chicken pox and hepatitis B—and keeping up with what they see as the life-or-death ones. But that can be a high-stakes game, as Kelly Lacek, a Pennsylvania mother of three, learned. She stopped vaccinating her 2-month-old son Matthew when her chiropractor raised questions about mercury in the shots. Three years later, she came home to find the little boy feverish and gasping for breath. Emergency-room doctors couldn't find the cause—until one experienced physician finally asked the right question. "He took one look at Matthew and asked me if he was fully vaccinated," says Lacek. "I said no." It turned out Matthew had been infected with Hib, bacteria that causes meningitis, swelling of the airway and, in severe cases, swelling of the brain tissue. After relying on a breathing tube for several days, Matthew recovered without any neurological effects, and a grateful Lacek immediately got him and his siblings up to date on their immunizations. "I am angry that people are promoting not getting vaccinated and messing with people's lives like that," she now says.

Health officials are angry too. Encouraged in part by the government report that seemed to clear vaccines of the autism charges, they are beginning to take a harder line with parents who submit vaccine exemptions for nonmedical reasons. In Maryland, where unvaccinated students are not permitted in school, officials last November threatened to take parents to court for truancy violations if their kids did not get all their shots so that they could be cleared for class. On Long Island, N.Y., vaccine objectors are called in for what some parents call "sincerity" interviews with school officials and school-board attorneys to determine how genuinely the vaccines conflict with religious convictions.

Even in cities where such interviews are not required, the tensions are palpable. Says Sue Collins, a New Jersey mother who has not had either of her two sons vaccinated: "Things are getting so nasty. People are calling us bad parents, saying it's child abuse if we don't vaccinate our children." In an effort to avoid potential conflicts, some parents are bypassing the school system altogether, preferring to homeschool their kids so they won't be forced to vaccinate them.

Common Ground
That still leaves the broader community at risk. So, is there room between public health and personal choice? Science may eventually provide a way out. Most people agree that there may be kids with genetic predispositions or other underlying conditions that make them susceptible to being harmed by vaccines. The Georgia girl in the recent vaccine case is the first such documented child, but her story suggests there could be others. Though CDC director Julie Gerberding was quick to insist that the case should not be considered an admission that vaccines can cause autism, some parents will surely take it as just that. "In rare instances, there could be some gene-vs.-exposure interaction that in theory could lead from the vaccine to autism," says Dr. Tracy Lieu, director of the center for child-health-care studies at Harvard Medical School. "The future of vaccine-safety research lies in trying to answer questions of genomic contributions to responses to vaccines." Screening for genetic profiles that are most commonly associated with immune disorders, for example, would be a good place to start.

Whether tests like these, combined with detailed family histories, will make a difference in the rates of developmental disorders like autism isn't yet clear. But such a strategy could reveal new avenues of research and lead to safer inoculations overall. Parents concerned about vaccine safety would then have stronger answers to their questions about how their child might be affected by the shots. Vaccines may be a medical marvel, but they are only one salvo in our fight against disease-causing bugs. It's worth remembering that viruses and bacteria have had millions of years to perfect their host-finding skills; our abilities to rebuff them are only two centuries old. And in that journey, both parents and public-health officials want the same thing—to protect future generations from harm.

An Old Scourge Returns.

Measles cases are on the rise as growing numbers of families forgo immunization

In the first four months of this year, 64 confirmed cases of measles were reported in the U.S., scattered across 11 hot spots. This is the most by this date for any year since 2001; 54 cases had links to other countries, and only one of the 64 patients had been vaccinated. The outbreaks in Arizona and San Diego can be traced to travel to and from Switzerland, where many people choose not to be vaccinated.

This article contains a complex diagram. Please click here to download.

The original version of this article incorrectly stated that Hib is a virus. In fact it is a bacteria.

great pictorial on the vaccine conundrum

Monday, June 2, 2008

On the public ethics of vaccinating or not?

via www.nytimes.com on 6/2/08
john:




“This goes at the heart of the public nature of infection disease and the the relatively libertian ethos of a pluralisitic society, we want to tolerate other's different choices, but if it puts my kid at risk, this is particularly stark insofar as there is a big upsurge in less than adequately immunized kids from the autism scare. Eventually, only a kind of social opprobrium, ie a shocked , you're not vaccinating your kids? will reverse the current trend toward succumbing to this kind of thinking.”




June 1, 2008
The Ethicist

Kicked Out of the Play Group

My daughter’s play group consists of children ranging in age from infancy to 4 years old. One mother revealed that she does not vaccinate her son. After much frank but cordial discussion and opinions from pediatricians — some thought she endangered our vaccinated kids; others did not — she felt pressured to leave the group. Did the group behave ethically? J.G., PASADENA

The group’s inclination was understandable, but its actions were unfortunate. Parents may — must — provide for their kids’ safety, but should not act unless that safety is truly threatened. Had you thought this mother was a witch who would cast wicked spells on your kids, you would have been wrong to purge her from your midst. A parent may prevent her child from being turned into a toad, but she may not exile someone when there’s no actual risk of toad-turning. You could, however, expel a member who is merely a social or cultural menace — a parent (or precocious but sullen 2-year-old) who curses like a drunken sailor, perhaps.

Did this mother present any such dangers? It can be a tough call to make when pediatricians offer contradictory advice, but the doctors I consulted say she did not imperil your kids, so I say you were wrong to push her out. Her views on vaccination are certainly benighted. Or as Dr. Mark Cullen of the Yale medical school more tactfully puts it, “The data on the harm from vaccines (e.g., autism) is such that the mother’s choice not to vaccinate is a very poor one for her own child.” That is, she endangers not your play group’s vaccinated kids but her own. She also jeopardizes other people’s unvaccinated children. Dr. Michele Barry, Cullen’s wife and also of Yale, cites a statistic from one study: “The likelihood of an unvaccinated child getting measles after exposure is anywhere from 22 to 224 times greater compared to vaccinated kids.”

Assuming that this mother is a congenial person (and you wouldn’t have included her otherwise), you should not exile her simply because she deviates from the group’s thinking. It is possible to socialize with people who have a diversity of ideas, even wrongheaded ones. As Dr. Johnson wrote, “a man accustomed to hear only the echo of his own sentiments, soon bars all the common avenues of delight, and has no part in the general gratification of mankind.” And he is a guy I’d want in my play group.

Thursday, May 8, 2008

China Hails Doctor For Raising Child Virus Alarm - New York Times

Sent to you by john via Google Reader:

via www.nytimes.com on 5/8/08
The New York Times

May 8, 2008

China Hails Doctor For Raising Child Virus Alarm

By REUTERS

Filed at 11:43 p.m. ET

BEIJING (Reuters) - A deadly strain of hand, foot and mouth disease has killed two more children in China, bringing the death toll in recent weeks to 32, state media said on Friday, as it praised a doctor who alerted authorities to the epidemic.

An eight-month-old girl and a boy aged one and a half, who both died in southern China, were the latest victims of an outbreak international experts have warned has yet to peak.

Hand, foot and mouth is a common childhood illness, but in the current outbreak, has been linked with enterovirus 71 (EV71) which can cause a severe form of the disease characterized by high fever, paralysis and meningitis.

The girl died early Monday morning in Guangdong province, which has registered four deaths from EV71, after emergency treatment failed, Xinhua said.

The boy, from the neighboring Guangxi region, started running a fever and coughing on Saturday but his parents didn't take him to hospital until Tuesday, when he fell into a coma. Doctors could not save him and he became Guangxi's second victim.

A cluster of EV71 cases in Fuyang in the central province of Anhui in March saw 22 deaths. Some 104 patients remain in critical condition across the province, official media has said.

The outbreak was not made public until late April, triggering memories of the deadly SARS epidemic that crippled China in 2003 and provoking calls for Fuyang officials to be sacked.

The World Health Organisation has said the delay was not because of any cover-up, but was due to problems local doctors faced trying to identify the illness.

China has since issued a nationwide alert, closing kindergartens and sending officials to visit nurseries and primary schools and educate staff on hygiene and prevention.

A U.S. health official offered to assist China in curbing the outbreak, and U.S. Health Secretary Michael Leavitt is to visit Beijing next week, Xinhua reported.

"We are willing to help China in any way possible with this issue," it quoted William Steiger, head of the Office of Global Health Affairs at the U.S. Department of Health, as saying.

State media Friday was filled with praise for a doctor who called in experts after she was baffled by the deaths of several children that colleagues insisted were just suffering severe colds or flu.

The official People's Daily carried a tribute with the headline "We salute you, Fuyang's Liu Xiaolin," comparing Liu to a doctor who helped lead the fight against the deadly SARS virus.

"We have no way to count how many children were treated and cured because of Liu Xiaolin's responsibility and steadfastness; there is also no way to calculate how many families avoided the epidemic because of her sharpness and courage," it said.

Liu had previously helped uncover a baby milk scandal, when fake formula made without key nutrients caused the death by malnutrition of several children.

(Reporting by Emma Graham-Harrison and Lindsay Beck; Editing by Nick Macfie)


Things you can do from here:

WHO Backs China's Reporting of Fatal Virus - WSJ.com

WHO Backs China's Reporting of Fatal Virus - WSJ.com: "Games in August. 'As far as I know, there is no severe case in Beijing at present,' he said.

Write to Jason Leow at jason.leow@wsj.com"
reassuring re chinese reporting, although it's odd that it's so severe. This is after all coxackie virus, a very common spring summer virus here that is generally a pain, but not very severe.

Friday, May 2, 2008

Measles Infections in United States - Medicine and Health - New York Times

Measles Infections in United States - Medicine and Health - New York Times
A reminder of the potential effects of the unfortunate backlash against immunizations. The article is accurate in describing that is all driven data-less almost hysterical fearmongering re vaccinations. Unfortunately it may take quite a number of sad stories of measles related brain damage for people to anchor the side of the risk equation, that we are preventing very bad diseases with these vaccines.

Virus Kills 22 Children in China - New York Times

Virus Kills 22 Children in China - New York Times
sounds like regular old coxackie virus, but that the children may have a more virulent form, and were more vulnerable because of poverty (health care, nutrition status)

Thursday, May 1, 2008

A Cure-All for Jet Lag? Try Caffeine and Naps - New York Times

A Cure-All for Jet Lag? Try Caffeine and Naps - New York Times: "g"

this is a pre-significant problem when picking up a young infant 12 hours aways like you do during overseas adoptions. Your exhausted, your adrenaline is completely flowing, and most parents crash pretty hard along with the kids sometime in the first week.
On performance enhancing with sleep phase shifts, bottom line,
when you switch,
get out in the sunlight,
drink caffeine,
take a nap,
and don't be over tired before and after your trip.
Save your sleep!

You'll be much more functional, less anxious, less irritable and will be able to enjoy the whole experience more.