DDP Newsletter March 2012, Volume XXX, No. 2.
Like clean water and clean air, a low incidence of infectious disease is a very good thing. But removing smaller and smaller traces of pollution, or the last cases of measles, becomes increasingly difficult and costly. Zealotry is a problem in and of itself. And at some point, efforts become counterproductive. “Clean” technology such as wind turbines may lead to more net pollution. What if more vaccines produce more net sickness?
Doctors may be hesitant even to ask this question. And families can be punished for failure to vaccinate. In Australia, for example, children must be fully immunized to receive the Child Care Benefit or the Child Care Rebate. In July, the Family Tax Benefit end-of–year supplement will also be tied to full immunization, which will soon include meningococcal C, pneumococcal, and chickenpox vaccines (ABC News [Australia] 12/5/11). In the U.S., such punitive actions are uncommon although children may be excluded from school or from many physicians’ offices.
The leading edge of compulsion is for annual influenza vaccination of health care workers (see November 2011 issue), even those who do not participate in patient care. The rhetorical temperature is rising; refusal is being portrayed as antisocial behavior.
“Newborn babies, the elderly, and the immunocompromised have a powerful interest in not being killed by those caring for them and in having a healthy workforce available to treat them,” writes bioethicist Arthur Caplan (Lancet 7/23/11, http://tinyurl.com/88jzze5). Moreover, he writes, “by not vaccinating themselves, health-care workers feed vaccine fears, reinforce anti-vaccine sentiment, and set a dismally poor example for the public.”
“Vaccination is a duty that one assumes in becoming a healthcare provider,” he concludes, “despite the loss of personal freedom entailed.” His assumptions are: that workers are “a powerful disease vector in a hospital” and that the efficacy of vaccination is a “proven fact,” as is “overwhelming safety.” Those who disagree are “delusional.”
“Herd immunity” is critical to protect those who cannot be adequately immunized” (Diekema DS, NEJM 2/2/12).
The policy of the American College of Physicians (ACP) states that discussion of immunization of medical personnel must begin with four “undisputed facts,” including that influenza vaccines are safe and effective. This is not undisputed: see November 2006 and September 2009 issues (http://tinyurl.com/6umvmxb and ddponline.org/2009).
Obviously, nosocomial infections occur, and there have been influenza outbreaks in hospitals that could be traced to unvaccinated staff members. Relevant facts cited by ACP: (1) 70% of health workers go to work when ill with influenza; (2) serologic studies suggest that up to 25% of health workers have evidence of influenza infection each season; (3) 50% of these infections are asymptomatic or have only minor symptoms.
Actual evidence for significant patient protection by immunizing medical personnel is scant. SHEA (Society for Healthcare Epidemiology in America) bases its 2010 recommendation for mandatory immunizations (http://tinyurl.com/6npvhwk) on four studies in long-term care facilities. A Cochrane review (http://tinyurl.com/cbsztrt) of “influenza immunization for heatthcare workers who work with the elderly” concluded that “there are no accurate data on rates of laboratory-proven influenza in healthcare workers” and that the studies they identified “are all at high risk of bias.” The effects they showed were for “outcomes with a non-specific relationship to influenza, namely influenza-like illness (which includes many other viruses and bacteria…)” and the overall mortality of the elderly. Winter influenza is responsible for less than 10% of the deaths of individuals over the age of 60, and overall mortality thus reflects many other causes.
Though citing this review, SHEA essentially dismisses it. SHEA acknowledges the criticism that results from long-term care might not apply to the acute-care setting, but states that a similar study there would be costly and challenging.
A review of nearly 6,000 studies of the efficacy of influenza vaccine found only 31 that met its eligibility criteria. It showed that influenza vaccines could provide moderate protection against serologically confirmed influenza, but this protection is greatly reduced or absent in some seasons, and that evidence for protection in adults over the age of 65 was lacking. The pooled effect in adults age 18 to 65 was reportedly 57% effectiveness (Lancet Infect Dis, January 2012, http://tinyurl.com/78mvlan).
While most adverse reactions to influenza vaccine are mild, severe effects can occur. “The worst nightmare for both the pharmaceutical industry and the health authorities,” stated Richard Bergström, Director-General of the European Federation of Pharmaceutical Industries and Associations, EFPIA, “is an illness that turns out to be mild, while the vaccine that was supposed to prevent a severe epidemic causes a severe side effect that was previously unknown.” The 2009 novel H1N1 “swine flu” vaccine Pandemrix was used in mass vaccination programs in Sweden, Finland, Norway, and Iceland, with heavy social pressure: “Be vaccinated to protect your fellow citizens.” The governments of these countries signed a contract protecting Glaxo Smith Kline from any financial claims if the vaccine had side effects.
In September 2010, Finland stopped all vaccinations with Pandemrix when cases of narcolepsy in children began to be reported. In Finland about 100 children were affected, and in Sweden at least 150. The incidence was about 6 per 100,000 persons between the ages of 4 and 19 who were vaccinated, a 12.7-fold increase over background.
The death rate from swine flu was 0.31 per 100,000 in both Germany, with a vaccination rate of 8%, and Sweden, with 60% vaccinated (Orthomolecular Medicine News Service 3/20/12, http://tinyurl.com/7ca62qb).
Although annual influenza vaccine is recommended for children, the inactivated vaccine does not appear to be effective for reducing influenza-related hospitalizations in children. In a cohort study performed at the Mayo Clinic, children who had received the flu vaccine had three times as many hospitalizations as those who did not, although the vaccine itself was not implicated as the cause of hospitalization (Science Daily 5/20/09).
A strategy called “cocooning” is now promoted by the American Academy of Pediatrics, especially to protect babies from pertussis before they can be immunized themselves—even though 10,000 to 20,000 people need to be vaccinated against pertussis to prevent one infant hospitalization. The American Council on Science and Health (ACSH) approvingly quotes Steven Weinreb: “We should not get vaccinated for ourselves alone; we should do it for one another. After all, we’re in the same herd” (NY Times 12/27/11, http://tinyurl.com/73jqfx2).
Previously, a 75% immunization rate was said to be adequate to protect the herd. Now, some claim 95% or more is necessary to prevent epidemics. The case for mandatory vaccination depends on this concept—but is it true? Because few people now have natural immunity to most vaccine-preventable diseases, the U.S. has been without a herd effect for 30 to 40 years, writes Russell Blaylock, M.D. Vaccine-induced immunity lasts for perhaps 10 years at the most, and “boosters” may be protective for only two (National Health Federation 12/2/09, http://tinyurl.com/7nfhvhc).
Immunization policy apparently is largely based on authoritative opinion, not evidence. On Apr 7, the Association of American Physicians and Surgeons (AAPS) filed a Freedom of Information Act (FOIA) request with the CDC seeking documentation pertaining to vaccine safety and efficacy on which its policy recommendations are based. Transparency is needed to dispel growing public distrust.