Written by: “RegularOldJoe”
To immunize or not to immunize, that is the question. Actually, are immunizations safe is probably the real question. Do they cause more harm than good? It seems like a simple question. Unfortunately, the answer completely depends on who you ask. If you ask a pediatrician, he or she will very likely be strongly in favor of immunizing. If you ask your “friends” on Facebook, you will get a whole spectrum of answers and most of them with very earnest convictions. Many of the answers will come from very well-intentioned, very opinionated, but possibly less educated people. Some will come from well educated, but somewhat misguided people. Almost certainly, most will have very strong personal opinions on the topic. So why does this dichotomy exist? Where does this rift originate? What is the real “truth” about immunizations? Let’s look at this in a little detail to try to sort it out. After all, you really want the real truth… not just my opinion… right?
First, let us clarify that not all immunizations are the same. I believe that the main impetus for all the hysteria about immunizations originates mainly from the very specific issues with the MMR vaccine and its possible association with Autism. Unfortunately, some people lump all vaccines together and decide to not get any immunizations at all “just to be safe”.
Some vaccines, such as Jonas Salk’s polio vaccine or Edward Jenner’s smallpox vaccine have quite literally saved millions of lives with very, very little concern for their safety. Nobody can really deny this fact. We went from hospitals with wards full of people in iron lung ventilators to essentially eliminating the entire disease of polio. Smallpox very literally was eliminated from the face of the earth with an extremely successful vaccine program to the point that we no longer even have to give the vaccine. I consider these two vaccines to be two of the all-time greatest achievements in medicine. Certainly these two are no-brainers and I truly believe the statistics unequivocally make their case.
Moving on to the DTP vaccine. This vaccine protects against diphtheria, tetanus, and pertussis (whooping cough). Most people today don’t personally know anybody who has ever had any of these three diseases and this is solely because of the vaccination program. I have never seen diphtheria in my 24 years of practice but have seen one very spectacular and tragic case of tetanus and several cases of pertussis. This combination vaccine can, and often times does cause fever. Severe reactions are very rare. The main reason that these vaccines are still so commonly recommended by pediatricians is because the organisms that cause these diseases are actually quite common in our everyday environment and the only reason that we don’t have extremely common occurrences of these diseases is because of the vaccines. Reported cases of pertussis vary from year to year and tend to peak every 3 to 5 years. Our last peak year nationally was in 2012, when 48,277 cases of pertussis were reported to the CDC. The only cases of whooping cough that we see today are in unimmunized or under-immunized people and it is very, very scary to see. A quick Google video search may be in order. After seeing just one case, I am convinced most people would be very quick to get their children immunized. The DTP immunizations require boosters every 10 years to keep you protected. Also, note that pertussis immunization is recommended for women in their 3rd trimester of pregnancy to help to transfer protection to the baby so that when it is born it is not so vulnerable while waiting to get its first DTP immunization at 2 months old. This is also why it is very important to be extra protective of your infant who is less than 2-3 months old when it comes to taking your baby out into public places. Anybody who knows me knows that this is really one of my “hills to die on”. I could not forgive myself if my infant acquired whooping cough or RSV due to MY DESIRE to show my baby off to the rest of the world. This is what Facebook is for. 🙂
Most adults only think about their DTP update every 10 years when they need a “tetanus shot” because they have a puncture wound or laceration, but really we need to remember to have these immunizations updated as part of routine well-visits….yes even for adults….and yes I am preaching to myself here too.
One other vaccine that has changed pediatric morbidity and mortality significantly is the HIB vaccine. This vaccine is often combined with the DTP shot to limit the number of injections (only for the pediatric regimens). This is a vaccine against the bacteria, Haemophilus influenzae B (NOTE: this is not the flu shot that is directed against the virus that causes flu). When I originally trained in Internal Medicine and Pediatrics, this organism was well known to cause major problems in young children. It could cause epiglottitis, pneumonia, meningitis and death in children less than 5 years old. It shaped the way we were trained to approach children with respiratory diseases so that we would never miss the potentially fatal diagnosis of HIB epiglottitis. Fortunately, the immunization came out in the early 90s and I have yet to see even a single case of HIB meningitis or epiglottitis. This vaccine is well-tolerated and again, there is not so much of a debate raging about this one.
Hepatitis B vaccine is one of the more recent vaccine developments and is recommended for infants in their primary vaccine protocols as a 3-shot series. Hepatitis B is a very serious infection worldwide. About a third of the world population has been infected at one point in their lives, including 240 million to 350 million who have chronic infections. Over 750,000 people die of Hepatitis B each year. It is spread through blood products and is also sexually transmitted. Infants are at particular risk and can acquire the infection from their mother at birth. The vaccine is very safe and very effective to the extent that the first shot is usually given to infants in the first few days of life. It is particularly important for healthcare workers since they may become exposed inadvertently. This is one of the vaccines that I recommend to patients as one way to do our part to improve the health of the world for generations to come.
Next I would like to discuss a few somewhat “gray area” immunizations, that I, as a physician and more importantly, as a father of 9 children, am a bit torn about. These are the chickenpox vaccine, the annual flu shots, and the politically charged HPV (human papillomavirus) vaccines.
Chickenpox vaccine is a vaccine against the Varicella-zoster virus (VZV). It was designed to prevent chickenpox which is a disease that most of us are familiar with. We may remember when we or one of our siblings had chickenpox as a kid and it was a nuisance, but, all in all, nothing that should warrant a vaccine program, right? Well, this is my explanation for why this vaccine was developed. Despite the fact that Varicella usually does only cause a fairly self-limited respiratory disease with the inconvenient scarring of the pox lesions themselves, there are actually quite a few deaths annually from complications related to chickenpox. Prior to the vaccine coming out in 1995, there were approximately 3-4 million cases of chickenpox annually with a little over 100 related deaths each year. Chickenpox is an extremely contagious disease and spreads quickly through the air when a person coughs. Interestingly, most of the severe cases are in the post-adolescent or adult age group. You are actually about 20 times more likely to die from chickenpox if you get it when you are an adult, and most Internal Medicine doctors have seen at least a few cases of severe life-threatening pneumonia related to the varicella infection. In most younger children it manifests as a much milder self-limiting disease. So why the big push to immunize children? (Warning: I am about to give my opinion which is not necessarily endorsed by the CDC or American Academy of Pediatrics.) I think that the main reason for the push to immunize children is because quite simply, this is the population that actually tends to get routine check-ups and immunizations. If you wait until adulthood, people tend not to go to the doctor for routine checkups, so doctors miss this important window of opportunity to immunize. Also, I have heard that the financial impact of a working parent having to take 10-14 days off work to care for an ill child was also taken into account when deciding to make the final recommendation by the American Academy of Pediatrics. The next most important question is, “How effective is the Varicella vaccine?” Well, as many of you may know, you can still get chickenpox after having the vaccine, but it will likely be much less of an illness. So bottom line….I recommend chicken pox vaccine to any post-pubertal patient who has not already had chickenpox. I am fine with not immunizing children and allowing them to get the wild virus as we know that an infection with the wild virus will provide lifelong immunity.
Annual flu shots are the immunizations that I get asked about most frequently. This is actually a very interesting and dynamic topic. First off, no I don’t recommend flu shots every year to every patient. There is no question that some years the flu shot truly saves lives as it is not uncommon to get secondary pneumonia following an influenza infection. These can be quite life-threatening. With this said, there have been years that I did not get myself or my family immunized against the flu. This is mainly because there is no reason to subject anybody to a vaccine where there is not clear evidence that the benefits outweigh the risks albeit the risks are quite minimal. Flu shots are different than other immunizations in that the flu comes around every year and the flu shot has to be adapted to the specific strains that are being predicted to be of greatest concern for that particular year. Some years (actually most years) the number of flu cases in our area makes me a huge proponent of the flu shot, other times there may not be very many cases of flu in our area or the flu shot may not be very effective that particular year….so basically, I play this one by ear. If there are lots of cases and the shot is at least moderately effective, then I recommend the flu shot…other times…not so much.
Ready for an interesting ethical debate? The HPV vaccine is directed toward the Human Papilloma Virus which is sexually transmitted and causes venereal warts and may subsequently lead to cervical cancer in women. When this vaccine first came out I was fairly against it as a uniformly recommended vaccine to all children, and I confess that I was morally outraged at the recommendations from the American Academy of Pediatrics in 2012 when they made the statement: “The AAP recommends routine HPV vaccination of males and females at 11-12 years of age.” At first, I thought, “Not my child, they don’t need this vaccine! They will never get any sexually transmitted disease!”. Then after I calmed down, I have come to soften my stance a bit. Let’s review. The way that a communicable disease is eradicated, such as with smallpox, is to produce what is called “Herd Immunity”. This means that enough of the population is immunized to prevent a widespread continuation of the disease and slowly the virus just dies out. The other thing to consider is that even if YOUR daughter is not sexually promiscuous and at high risk of sexually transmitted diseases, this virus is very common and most of the time asymptomatic and can lay dormant for years, therefore in the future when your virginal daughter gets married and has sex for the very first time, she could be at risk of a sexually transmitted disease that is actually completely preventable with a very safe vaccine. So, all this to say, I’m not so against it anymore.