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Vaccine Safety: Evidence-Based Research Must Prevail

Dimensions of Critical Care Nursing: May/June 2017 - Volume 36 - Issue 3 - p 145–147
doi: 10.1097/DCC.0000000000000250
DEPARTMENTS: Editorial

Kathleen Ahern Gould, PhD, RN Editor in Chief, Dimensions of Critical Care Nursing Adjunct Faculty, William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Scientific evidence has soundly rejected claims that autism is caused by vaccines. The science is clear, and research continues to support this evidence. Surprisingly, detractors still emerge now and again. Our role as medical professionals requires that we know the facts and continue to educate families, patients, and the public.

Recently, as I thought about an editorial, I was stunned to read an article in the Washington Post attesting to the fact that our new President may consider appointing a vaccine skeptic to lead an effort on vaccination safety.1 This is frightening information—a call to action for evidence-based health care providers!

Political figures and celebrities have created confusion and fueled inaccurate discussion on this topic for years, yet the science is clear. Misinformation has been corrected. Evidence-based guidelines and professional recommendations should prevail; however, as Kent Anderson recently reminded us, norms and assumptions, even science, are no longer certain. We live in strange times and in a bizarre political climate, unlike anything we have ever seen.2

In these uncertain times, it is imperative that facts and evidence prevail and professionals continue to inform and teach about vaccine safety. We know that the link to autism has long been debunked—this issue is settled, and there is nothing new to debate. However, misinformation circulates and reemerges often. Such discussions often occur when political figures, or people with substantial power, influence and voice, create new debate, and spread misinformation. On these occasions, it is critical that medical professionals voice their knowledge and present the evidence in clear and concise language—each time this debate begins anew.

Dr Atul Gawande reminds us that misinformation sticks and becomes a mental model. As scientists, we must continue to break down misconceptions and break false models. He reminds us how to build trust in science and tells us to be prepared to assert true facts: don’t focus on myth—focus on facts—and present stories of success. He reinforces scientific facts in his teaching to young scientists as he reminds them—vaccines do not cause autism, they simply don’t. He tells us that correlation is not causation and we must follow the best evidence to search for truth.3

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VACCINE SAFETY: DEBUNKING THE MYTH

As professionals, we continue to teach, explain, and present the scientific explanations that expose bad science, break patterns, debunk misinformation, and help people judge information by scientific merit. Few medical professionals remember a world without vaccines but can attest to the fact that vaccines are the best tools we have to control disease and prevent millions of deaths worldwide. However, real fears persist about the cause to very visible and heartbreaking condition such as Autism.

So what motivates vaccine-averse people? Seth Mnookin, Massachusetts Institute of Technology professor and author of The Panic Virus, a 2011 book on vaccinations and their opponents, tells us that 1 factor may be the very success of the vaccines. He reminds us that generations of Americans lack their parents and grandparents’ visceral fear of polio; for example, “For those people, you might as well be protecting against aliens—these are things they’ve never seen.”4,5

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HISTORY OF THE VACCINE CONTROVERSY

The vaccine versus autism controversy began in 1998 after The Lancet, a respected medical journal, published an article by researcher Andrew Wakefield and colleagues. The (now retracted) article was the first to link the measles, mumps, and rubella vaccine to autism. A sample of only 12 subjects and speculative conclusions launched a global movement joined by celebrities including Jenny McCarthy, who warned parents to stop vaccinating their children. A drop in MMR vaccinations followed.6

The article was published in The Lancet on February 28, 1998. It was retracted on February 2, 2010—a full 12 years after it appeared! Authored by Andrew Wakefield, John Walker-Smith, and 11 others from the Royal Free Medical School, London, the original article reported on 12 developmentally challenged children and triggered a decade-long public health scare.7 The article and its conclusions were grossly inaccurate.

Moreover, the study was a found to be a complete fraud. The Lancet, a distinguished medical journal, determined that attorneys for parents who had brought lawsuits against vaccine companies had funded Wakefield. In 2010, when the journal finally retracted the article, Wakefield was stripped of his medical license.1,4,6 He remains the face of this debate, and his work is a model of “bad science.” However, misinformation took hold at a global level and was perpetuated for many years.

One major problem was that The Lancet took 12 years to retract the article, by which time its false information had spread like wildfire. Even as confidence slowly returned in Britain, the scare took off around the world, unleashing fear, guilt, and infectious diseases and fuelling suspicion of vaccines in general!

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DISRUPTIONS IN HERD IMMUNITY

As a result, measles outbreaks and other infections reemerged globally. In 2010, California reported 10 babies dead from whooping cough, in the worst outbreak since 1958.8 On January 5, 2015, the California Department of Public Health (CDPH) was notified about a suspected measles case. The report from the Centers for Disease Control and Prevention reflects the scope of how illness spreads in unvaccinated individuals, highlighting the importance of herd immunity, a well-known public health concept as a condition necessary to eradicate communicable diseases.9

A wake-up call for the United States occurred when the measles came to Disneyland. The 2015 outbreak of measles that started at Disneyland turned a spotlight on those who choose not to vaccinate their children.4 The Centers for Disease Control and Prevention tracked the outbreak carefully.

The California outbreak began with a hospitalized, unvaccinated child, aged 11 years with rash onset on December 28. The only notable travel history during the exposure period was a visit to one of two adjacent Disney theme parks located in Orange County, California. On the same day, CDPH received reports of four additional suspected measles cases in California residents and two in Utah residents, all of whom reported visiting one or both Disney theme parks during December. By January 7, seven California measles cases had been confirmed, and CDPH issued a press release and an Epidemic Information Exchange (Epi-X) notification to other states regarding this outbreak. Measles transmission is continued.9

As of February 11, a total of 125 measles cases with rash occurring during December 28, 2014–February 8, 2015, had been confirmed in US residents connected with this outbreak. Of these, 110 patients were California residents. Thirty-nine (35%) of the California patients visited one or both of the two Disney theme parks during December 17–20, where they are thought to have been exposed to measles, 37 have an unknown exposure source (34%), and 34 (31%) are secondary cases. Among the 34 secondary cases, 26 were household or close contacts, and eight were exposed in a community setting. Five (5%) of the California patients reported being in one or both of the two Disney theme parks during their exposure period outside of December 17–20, but their source of infection is unknown. In addition, 15 cases linked to the two Disney theme parks have been reported in seven other states: Arizona (seven), Colorado (one), Nebraska (one), Oregon (one), Texas (one), Utah (three), and Washington (two), as well as linked cases reported in two neighboring countries, Mexico (one) and Canada (10). In this case, some of the unvaccinated patients (12) were infants too young to be vaccinated. However, the 37 remaining vaccine-eligible patients, 28 (76%) were intentionally unvaccinated because of personal beliefs, and one was on an alternative plan for vaccination.9

The popular press and politician responded quickly by asking, “How did we get to a point where personal beliefs can triumph over science?”10 California Governor Jerry Brown bravely and boldly responded to the measles assault by signing a bill to make the state’s vaccine policy one of the strictest in the country.11 The bill, eliminating personal and religious exemptions, was passed only a few months after measles were reported in Disneyland. The California bill would outlaw a family’s personal and religious beliefs as reasons to exempt their children from school vaccinations.

“The science is clear that vaccines dramatically protect children against a number of infectious and dangerous diseases,” Brown wrote in a signing statement. “While it’s true that no medical intervention is without risk, the evidence shows that immunization powerfully benefits and protects the community.”12

At the time of this event, all 50 states required children to be vaccinated before they start public school; however, 20 states had exemptions for parents’ religious or philosophical beliefs.11,12

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MEASLES: AN OLD THREAT REQUIRES NEW VIGILANCE

A recent editorial by Alspach13 reminds us that measles has never been totally eradicated from the United States. However, we must remain vigilant and consider that many of the common symptoms that we commonly see may be an old disease reemerging. Although many of us have never seen measles, we must keep up a healthy index of suspicion. To keep our communities safe, we must know the signs and symptoms of this disease. Providers must be suspicious if patients appear with fever, rash, and characteristic signs such as the 3Cs (conjunctivitis, coryza, and cough), especially if they also are not vaccinated against measles, live in an area experiencing cases of measles, or report recent travel (or were exposed to someone who recently traveled) outside the United States. A frightening statistic tells us that 1 to 2 of every 1000 children who get measles die. Complications are more likely in children younger than 5 years and adults older than 20 years. High risk exists for pregnant women and anyone with compromised immune system.13

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CONCLUSIONS

Vaccines may be the most important tool we have to prevent diseases. Vaccines prevent 6 million deaths every year worldwide. Experts agree that the benefit of vaccines is not a matter of opinion but a matter of scientific fact.14,15 Extensive meta-analysis and Cochrane reviews continue to support this message and debunk fears about links to autism or other diseases.16,17

In times of political uncertainly, changes in power, and shifts in worldviews, we must clarify and protect our evidence-based knowledge about vaccines. Parents, families, and public citizens may ask you about the safety of vaccines. The reference list and tables provide resources that will help lead these important discussions. As a consumer of research, and ambassador for population health, please begin by sharing this short 12-minute video (Table 1), post it on social media, or use it for all formal and informal teachings. More information to support parents and provide scientific evidence on vaccine safety is provided in Table 2. Please use these tools to educate and inspire others.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

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References

1. Phillip A, Sun LH, Bernstein L. Vaccine Skeptic says Trump Asked Him to Lead Panel on Inoculations. The Washington Post. 2017.
2. Anderson K. Scientific publishing in a time of political assaults. The Scholarly Kitchen. January 31, 2017. https://scholarlykitchen.sspnet.org/2017/01/31/scientific-publishing-time-political-assaults/. Accessed February 1, 2017.
3. Gawande A. Caltech commencement address. 2016. https://www.youtube.com/watch?v=e4oH8vhXSbM. Accessed December 10, 2016.
4. Haberman C. A discredited vaccine study’s continuing impact on public health. New York Times Retro Report. February 1, 2015. https://www.nytimes.com/2015/02/02/us/a-discredited-vaccine-studys-continuing-impact-on-public-health.html?partner=rss&emc=rss&smid=tw-nytimesscience&_r=1. Accessed January 28, 2016.
5. Mnookin S. The Panic Virus: A True Story of Medicine, Science, and Fear. New York, NY: Simon and Schuster; 2011.
6. Deer B. How the case against the MMR vaccine was fixed. BMJ. 2011;342:c5347.
7. Wakefield AJ, Murch SH, Anthony A, et al. Ileal lymphoid nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637–641.
8. California Department of Public Health. Pertussis report. www.cdph.ca.gov/programs/immunize/Documents/PertussisReport2010-12-15.pdf.
9. Zipprich J, Winter K, Hacker J, Xia D, Watt J, Harriman K; Centers for Disease Control and Prevention (CDC). Measles Outbreak—California, December 2014–February 2015. MMWR Morb Mortal Wkly Rep. 2015;64(6):153–154. http://www.cdc.gov/mmwr. Accessed January 28, 2017.
11. Knapp M. California Gov. Jerry Brown signs mandatory vaccination bill. CNS News. July 1, 2015. http://www.cnsnews.com/news/article/margaret-knapp/california-gov-jerry-brown-signs-mandatory-vaccination-bill. Accessed January 5, 2017.
12. Martinez M, Watts A. California vaccine bill that bans personal, religious exemptions advances. CNN Health. June 25, 2015. http://www.cnn.com/2015/06/25/health/california-vaccine-bill/. Accessed January 28, 2017.
13. Alspach JG. Measles: Eliminated but Not eradicated. Crit Care Nurs. 2015;35:9–13.
14. Gupta S. Benefits of vaccines are a matter of fact. http://www.cnn.com/2017/01/10/health/vaccines-sanjay-gupta/. Accessed January 10, 2017.
15. American Association of Pediatrics. Vaccine safety: examine the evidence. Healthy Children. https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Studies-Examine-the-Evidence.aspx. Accessed January 31, 2017.
16. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32(29):3623–3629.
17. Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C. Vaccines for measles, mumps and rubella in children (review). Cochrane Database Syst. 2012;(2):CD004407.
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