By Bernadine Healy, M.D.
When Larry King used the word debate to describe his April 3 program on vaccines and autism, he might just as well have said war; the airways smoked as activist Jenny McCarthy, mother of a child diagnosed with autism who blames vaccines, and her partner, Jim Carrey, faced off with two distinguished pediatricians representing the American Academy of Pediatrics. McCarthy and Carrey and two colleagues from the autism advocacy group she founded, Generation Rescue, took the AAP to task for its unwillingness to give at all in the controversy over vaccine safety and, while holding up a vaccine ad in its journal, accused the group of shilling for vaccine manufacturers.
The academy's goal is to get every child in America—that's 4 million born per year—vaccinated fully and on time in order to avoid perilous consequences such as a recent deadly outbreak of hemophilus influenza that could have been prevented with the Hib vaccine. The pediatricians took umbrage at the criticism and insisted that vaccine safety issues have been resolved to the fullest. I was there in the crossfire, arguing as I have many times that, yes, vaccines are eminently safe—and parents are raising legitimate concerns, yet unanswered. This controversy might be resolved if we can focus on a few big questions, with an open mind.
[Find out why vaccine safety is getting new attention.]
First, are we overvaccinating our children? Vaccines are powerful stimulants of the immune system, which they must be to be effective. But as many of the autism activists have pointed out, American children are the most vaccinated on the planet. Generation Rescue and the World Health Organization both have compiled data that show the United States now gives more vaccines to all its children, and earlier in life, than the rest of the developed world: some 36 doses before our little ones hit kindergarten, with most crammed into the first 18 months of life. If you look at the best-performing countries in terms of infant and early-childhood mortality, the average number of doses is 18, with most of the Scandinavian countries, Japan, and Israel mandating just 11 to 12.
The extras here include protection against the sexually transmitted hepatitis B virus, which many countries (and the United States in the past) recommend only for infants at high risk because of an infected mother; a vaccine against the rotavirus, which causes some cases of infant diarrhea; and one for the foodborne hepatitis A virus, typically given to travelers to high-risk places. Many countries don't recommend chicken pox vaccine, which may not afford the long-term immunity that comes from childhood infection, important since this virus is tougher on adults. Influenza vaccine, mandated here starting at age 6 months, is off almost everyone else's list.
Second, is the schedule of vaccinations too rigid? The Centers for Disease Control and Prevention sets a schedule for when children need their different vaccines; the first shot, hepatitis B, comes when they are but hours old. Though it is important that parents keep to the vaccine schedule in general, some experts wonder whether the shots should be spread out in some circumstances. Might moms who regularly breast-feed follow a less aggressive schedule, since they share their protective antibodies with their infants? The science on this is still skimpy. And a study from Canada last year found that delaying the diphtheria, tetanus, and pertussis vaccination just a few months decreased by 50 percent the risk that a child develops asthma. These findings need to be studied further, and embarking on such an effort should not be interpreted as an antivaccine pursuit.
[Hear from 2 doctors on the pros and cons of a flexible vaccine schedule.]
Meanwhile, pediatricians might do families a great service if they could work with them to loosen up the schedules to accommodate reasonable concerns and allow more choice. Some already do—say, by spacing out shots that are normally given in one visit, particularly those that contain live viruses like measles, mumps, and chicken pox and tend to deliver strong immune reactions. Or delaying hepatitis B until school age, at least. The goal is to get all kids appropriately vaccinated, but the pace for that might vary.
[Check out advice for parents who want to manage their child's vaccination schedule.]
Finally, are certain groups of people especially susceptible to side effects from vaccines, and can we identify them? Youngsters like Hannah Poling, for example, who has an underlying mitochondrial disorder and developed a sudden and dramatic case of regressive autism after receiving nine immunizations, later determined to be the precipitating factor. Other children may have a genetic predisposition to autism, a pre-existing neurological condition worsened by vaccines, or an immune system that is sent into overdrive by too many vaccines, and thus they might deserve special care. This approach challenges the notion that every child must be vaccinated for every pathogen on the government's schedule with almost no exception, a policy that means some will be sacrificed so the vast majority benefit.
These are all reasonable issues, and considering them with some flexibility would go a long way to resolving many of the frictions aired by Larry King. President Obama and other leaders have recognized that the vaccine-autism connection is not resolved, and research on autism is singled out as a priority in the president's current budget. Some have lobbied to keep vaccines out of the government's autism research agenda, because they see the case as closed and fear further study will threaten confidence in vaccines. Doing so would be just plain wrong.
Less than a year ago, the National Institutes of Health put out a call for expanded research on vaccine safety that contains many of the very things that parents are asking for: examination of the way the immune system handles different vaccines, the impact of nonvaccine components (like mercury and aluminum), and better understanding of susceptibility to vaccine side effects. The government laid out the need for markers that might predict vulnerable groups and proposed research on the comparative effect of different vaccine schedules and combinations of vaccines. This work is long overdue; shockingly, so is a study comparing groups of vaccinated and unvaccinated children.
Paul Offit, an infectious-disease expert from the University of Pennsylvania who has been a frequent spokesman and adviser on vaccine policy (and by his admission has become wealthy by developing the now mandated rotavirus vaccine), has said on more than one occasion that the infant's immune system can handle 10,000 vaccines. If that's where we're going—and it has been estimated that there are more than 100 new vaccines in the pipeline—the national investment in vaccine safety had better get on steroids fast. More medicine is not always better medicine. As the move toward health reform recognizes, this can make for poor public health policy—and break the bank.