Wisdom Teachers

The advocate: Q&A with a vaccine champion

'Misinformation surrounded the [H1N1] vaccine, but it was the virus that killed people.'

Paul OffitPaul Offit, MD, infectious disease chief at the Children's Hospital of Philadelphia, has been front and center in the fight against the growing anti-vaccine movement — and he has the hate mail to prove it. As vaccines are the primary firewall against emerging and reemerging infectious diseases, Offit's stand is an important one for the infection preventionist. Indeed, nosocomial outbreaks of vaccine-preventable diseases have been reported in recent years as measles and mumps make a comeback. These outbreaks can be very disruptive and expensive, as a hospital recently reported a mumps outbreak ended up costing more than a quarter of a million dollars.1

Offit is the author of the books The Cutter Incident: How America's First Polio Vaccine Led to the Growing Vaccine Crisis (R.R. Donnelly & Sons; Chicago) and Autism's False Prophets: Bad Science, Risky Medicine, and the Search for a Cure (Columbia University Press; New York City). He is a member of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP), which voted Feb. 24 to recommend universal seasonal flu immunization. The move to vaccinate everyone 6 months and older unless contraindicated (e.g., egg allergies) also ratchets up pressure on health care workers, a group that has long resisted standing CDC recommendations to be immunized for seasonal flu.

Q. Did the H1N1 situation give ACIP a sort of "pandemic push" to move to universal immunization?

A. The momentum actually has been building for years prior to H1N1. As more and more groups were recommended to receive the vaccine, it got to the point where 85% of the U.S. population were considered to be in a group recommended to receive influenza vaccine. So, it's really in some ways easier to define who shouldn't receive the vaccine than who should receive it. Going to a universal recommendation for an influenza vaccine meant only increasing those for whom it's recommended by 15%. It was the logical thing to do. Everybody is at risk of getting influenza and suffering, being hospitalized or being killed by it.

Q. You were somewhat skeptical about the threat of the H1N1 pandemic last year after the first wave How do you think the pandemic has played out?

A. It wasn't the 1918 pandemic, but it was a pandemic worth preventing. What if I told you there's going to be a virus coming to the United States which will infect about 55 million Americans, cause about a quarter of a million to be hospitalized, cause about 11,000 — including about a thousand children — to die, but I have a vaccine that will prevent a lot of that. Would you be willing to take it? I'd like to think the answer for most people would be, "Yes."

Q. Unfortunately, there were a lot of people who didn't want to take it, including health care workers. Was there some kind of perception problem about this pandemic? It seems there were some mixed messages about the threat.

A. I'd like to think that's also something we learned from this. The prediction very early on was that we could have as many as 90,000 deaths. That came from the government — they were preparing that it might be that many. Fair enough, but the way it got communicated to the public was that it would likely be that many. And when it was about a tenth of that, people felt that they hadn't been told the truth. In the future, we need to provide a range of what one could potentially see and communicate that message.

Q. As H1N1 infection proved moderate in many cases, attention seemed to shift to the safety of the vaccine, even though you have pointed out it proved "remarkably safe."

A. There certainly was a lot of misinformation about safety. Suddenly it's a new process, whereas the fact is it was made exactly the same way that the seasonal vaccine's made. There were [claims and fears that] it contained thimerosal and was harmful. Obviously, thimerosal at the level contained in the vaccine was certainly not harmful. Some put out information that it contained an adjutant, which actually it didn't contain. So the usual sort of safety misinformation surrounded this vaccine, but it was the virus that killed people. CNN had a [television screen] crawl line that said, "Which is worse, the vaccine or the virus?" I just think it was wholly irresponsible to have that kind of information out there. And the media will never, ever blame themselves for this. They have this sort of journalistic mantra of balance which is to tell two sides of the story when only one side is supported by the science. We all suffer from that false "balance."

Q. You have been one of the leading voices speaking out against the growing anti-vaccine movement. Did you feel vindicated when The Lancet recently retracted the 1998 article2 that appeared to link autism to the measles, mumps rubella [MMR] vaccine?

A. It should have never been published; nothing was ever studied. It was simply a case series, which said there were children who had received the MMR vaccine and within a month had first been noticed to have symptoms of autism. That's not a study. At best, you can say that British group raised a hypothesis, but they didn't test the hypothesis. If you have an outlandish hypothesis — in this case of vaccine causing autism — I think that in order to be published you should have far more supportive data. There were no data. The old line from Carl Sagan is that "extraordinary claims should be matched by extraordinary evidence." This was an extraordinary claim with no evidence. And so all it did was frighten people. When studies were done — when you actually compare children who received or didn't receive MMR and see that the risk of autism was the same in both groups — then you had your answer. I think the editor or The Lancet should have turned that paper back [originally] and said, "Come back to us when you have data that actually examine your hypothesis."

Q. We've seen the celebrities on TV, concerned parents groups, and now more reports of community and hospital outbreaks with vaccine-preventable diseases. Does a lot of the current anti-vaccine movement go back to this retracted study?

A. Yes, this opened Pandora's box. Because it had the imprimatur of an excellent medical journal, it had the backing of a very well respected hospital — the Royal Free Hospital in London. It had the backing of well-respected or well-known gastroenterologists. Respected academicians put their names behind this outlandish notion. And it gave birth to the general idea that vaccines could cause autism. I think that will not go away until we know what the real cause or causes of autism are.

Q. Can we expect the lack of herd immunity to vaccine-preventable diseases to continue causing sporadic outbreaks in communities and hospitals?

A. Yes, that's exactly right, and I think that's what has happened. If you take a step back and look at overall immunization rates in the U.S., they're actually very good. But there are certain pockets and communities where they aren't, and that's where you see these outbreaks. So yeah, I think now we've seen outbreaks of mumps, measles, and a type of bacterial meningitis — all of which are preventable by vaccination. We've seen outbreaks of pertussis. I think there's every reason to believe that you could see diseases like polio come back in the United States. It is certainly in the world, and international travel is common.

References

  1. Bonebrake AL, Silkaitis C, Monga G, et al. Effects of mumps outbreak in hospital, Chicago, Illinois, USA, 2006. Emerg Infect Dis 2010 March [serial on the Internet]. Available at: http://www.cdc.gov/EID/content/16/3/426.htm.
  2. Wakefield AJ, Murch SH, Anthony A, et al. RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351:637-641.