Vaccine Vacillations Rile Parents, Physicians and Officials by Carolyn Cosmos I think itís unconscionable to reject childhood immunizations. I donít think its right unless thereís a health risk for your child. Iím a believer in the public health system,î said Amanda Bickel, 35, of Boulder, Colo. The mother of newborn Miles and Zach, 3, Bickel is an analyst for the Colorado legislature. She and her engineer husband Peter Meyer hold that ìmost of the diseases we vaccinate for are extremely serious, and the small risks associated with vaccines are well worth it.î So Zach has gotten all of the shots recommended for a child his age by the American Academy of Pediatrics (AAP), and Miles undoubtedly will as well. On the other hand, thereís Ingri Cassel. ìOur position is that no one should have any shots of any kind for any reason,î Cassel said. Sheís the director of Vaccination Liberation, a civil liberties organization in Coeur díAlene, Idaho, which holds that vaccinations do more harm than good. Vaccination Liberation opts instead for improved general health, better nutrition, and the elimination of environmental hazards. Cassel rejects some scientific thinking about the immune system, and sheís also skeptical of large-scale studies that link vaccinations to reductions in diseases. Clearly thereís a tug of war going on about vaccine shots. Cassel and Bickel are two ends of a knotted rope entangling physicians, public health officials and parents in the United States and the United Kingdom alike, with reverberations being felt around the globe. Bickel herself isnít uncritical of vaccinations. She typically takes a hard look at the recommended shots in Zachís schedule and talks things over with her pediatrician. ìIf itís a new vaccine, my tendency is to wait,î she said. However, when it comes to one of the hottest vaccine topics in the United Kingdom and the United Statesóan alleged link between autism, childhood bowel disease and the MMR vaccine for measles, mumps and rubellaóBickel brushed it off: ìI did ask my doctor about it, and she said there was no evidence to support it whatsoever.î Rep. Dan Burton (R-Ind.), chairman of the House Committee on Government Reform, isnít so sure. He held hearings on the autism-vaccination link on June 19, saying that ìa majority of parents whose children have late-onset or acquired autism believe it is vaccine related.î And across the Atlantic, the mayor of London, Ken Livingstone, got into trouble with the U.K. Department of Health for telling parents to reject the MMR combination vaccine and get single shots instead. The incident generated a ìvaccine blunderî headline in The Guardian. Meanwhile, the entire immunization-safety issue has been ratcheted up by the anthrax attacks in Washington, D.C., last fall and the recently released and controversial plans in the United States to vaccinate health care workers against the possibility of a smallpox bioterrorist attack. In the middle of the muddle are some with mixed views. The American Association for Health Freedom in Great Falls, Va., is a civil liberties lobbying group for physicians who include in their practices alternative medicine use. The group holds that ìvaccinations have essentially extinguished many illnesses that plagued our society [but] children should not be forcefully subjected to unreasonable amounts of vaccinations to combat diseases that primarily affect adults.î Dr. Arthur Krigsman is a pediatric gastroenterology consultant from New York who testified at Rep. Burtonís hearings. He told the congressional gathering that he found evidence of bowel disorders in autistic children that merited further research. Specifically, he found intestinal troubles in the majority of the 43 autistic children he examined, with some pathologies appearing in 90 percent of the cases, possibly suggesting a link to the measles vaccine. Krigsman did note that he was ìnot anti-vaccineî and had all of his pediatric patients vaccinated. At the other end of the spectrum is Dr. Cody Meissner, chief of the Pediatric Infectious Diseases Division at the New England Medical Center in Boston, who said that people trying to block childhood immunizations are practicing ìa type of bioterrorismî and do not have any credible science to back them up. Meissner, who is also a member of the Committee on Infectious Diseases at the American Academy of Pediatrics, said heís particularly concerned about the effects that allegations linking autism to the MMR vaccine have on parents and their decision to vaccinate. According to the Centers for Disease Control and Prevention (CDC), a child is at much greater risk of contracting a potentially deadly measles, mumps or rubella-related disease than of developing a fatal disease from a vaccine. For instance, an unvaccinated child has a one-in-20 chance of contracting measles-related pneumonia, a one-in-2,000 chance of contracting measles-related encephalitis (brain inflammation), and a one-in-300 chance of contracting mumps-related encephalitisóas opposed to a one-in-1 million chance of developing encephalitis from an MMR vaccine. Meissner also noted that ìpeople in the United Kingdom are not getting vaccinatedî because of the anti-vaccine movement, pointing particularly to problems with measles that have emerged as a result of the movement. ìWe have had several outbreaks or clusters of measles, the latest of which was in the London area,î confirmed Dr. Marjorie Monnickendam, a health official with the U.K. Public Health Laboratory Services (PHLS). For example, immunization rates for one group of British children (ages 16 months) have dropped because of the controversyófrom 72 percent in April to 69.4 percent in May. Unlike the United States, where schoolchildren must be vaccinated in all 50 states unless parents get a medical, religious or philosophical exemption, childhood immunizations in the United Kingdom are not required. The controversy does not seem to be having the same practical impact here. Said Meissner, ìWe have a higher immunization rate in the U.S. than weíve ever had before, and weíre seeing a lower incidence of infections.î The CDC, for example, reported in April that measles and rubella had been nearly eliminated in this country, in part because of global immunization efforts and fewer cases coming in from other locales. In the United States, there were only 108 confirmed cases of measles in 2001, according to the CDC, and only 522 total in the Western Hemisphereódown from 1,760 cases in 2000. These optimistic statistics, however, donít tell the whole story. According to the World Health Organization (WHO), about 1 million children still die from measles each year. Present WHO statistics show that the highest measles rates occur in Southeast Asia, Africa and the Middle East. The United Kingdomís PHLS also points out the dangers to children in any given measles outbreak: In Italy, for instance, relatively low childhood immunization rates (53 percent to about 80 percent) have led to 24,000 measles cases in southern Italy this year alone, which have resulted in 13 cases of encephalitis and three deaths among children under the age of 14. Nevertheless, there is some anecdotal evidence of parental concern in the Washington, D.C., area about immunizations in general and the MMR vaccine, which is actually three vaccines in one shot. According to Joan Tolbert, a registered nurse with Chevy Chase Pediatrics in Washington, D.C., a few parents in the large practice have been worried about immunization safety and have asked about the autism connection to vaccines. Tolbert reported that at least two parents have requested that the MMR vaccines be given one at a time, and several were concerned about the total number of immunizations. Most, however, go ahead with the shots. Similarly, at clinics run by the Childrenís National Medical Center in Washington, D.C., ìonly a couple of parents have come in with concerns about MMR and autism,î said the centerís Dr. Nathaniel Beers, who is also an assistant professor of pediatrics at George Washington University. ìQuestions tend to come from more highly educated parents with more access to information,î Beers noted. Meissner, of the New England Medical Center, largely attributes the vaccine-autism uproar to one ìcharismaticî U.K. physician and researcher, Dr. Andrew Wakefield, who now resides in Florida. Wakefield first raised the issue in 1998 when he published a controversial study in The Lancet of 12 children who demonstrated a link between the MMR vaccine, bowel disorders and autism. Some of the children seemed normal at birth and then regressed into autistic behaviors after they received the MMR shot. However, Beers said that there is no current scientific support for the alleged autism links to the measles vacci ne. Added Meissner, ìOther labs didnít duplicate his findings. This is not a credible movement. Itís one person against the whole medical and scientific establishment. Heís a kook.î These two pediatric physicians at major medical institutions have the preponderance of the evidence on their sideóalthough there have been some small openings for science-oriented doubters and anguished parents. ìWe pediatricians really feel for families who have children with autism spectrum disorders,î Beers said, ìbut weíre not able to substantiate [the vaccine link] in any way. Every parent who has a child with a serious developmental disorder needs to figure out why this has happened to their child. But thereís not going to be a clear-cut answerî at this point, he said, although new research is providing some ìbetter understandings.î Carolyn Cosmos is a freelance writer in Washington, D.C. Study Results Favor Use of MMR Vaccine Hereís a look at some of the studies and position statements on the measles-mumps-rubella vaccine (MMR) and its alleged link to autism, including an Institute of Medicine review that does not totally reject a possible link. The World Health Organizationís (WHO) Vaccines and other Biologicals Department ìcontinues to recommend the use of MMR vaccines based on a proven record of effectiveness and safety.î Although ìit has been postulated that receipt of the MMR vaccine may be associated with autism, Crohnís disease and other bowel abnormalities,î WHO sees ìno proven causal relationship Ö between immunization with measles-containing vaccines and these events.î According to the Centers for Disease Control and Preventionís (CDC) National Immunization Program, ìThe weight of currently available scientific evidence does not support the hypothesis that the MMR vaccine causes autism. [The] CDC recognizes there is considerable public interest in this issue, and therefore supports additional research regarding this hypothesis.î The CDC position is based on scientific studies and expert reviews conducted in Sweden, the United Kingdom and the United States. The Medical Research Council (MRC) in the United Kingdom convened an expert group to examine the issue. The group concluded in a December 2001 report that there is no causal link between the MMR vaccine and autism or inflammatory bowel disorders. The National Autistic Society (NAS) in the United Kingdom stated its support for the MMR vaccine and said there is ìno conclusive scientific evidenceî to back an MMR-autism link. Justice Awareness and Basic Support (JABS) in the United Kingdom, a ìself-help group for vaccine-damaged children,î holds that ìthere is much anecdotal and scientific evidence to support a link between MMR vaccine, bowel disease and other neurological problems which tends to be dismissed.î JABS ìaccepts that the majority of children suffer no ill-effect from immunisation but is concerned that very few studies have been done as to the long term effects.î The American Academy of Pediatrics (AAP) states that the ìMMR vaccine is safe and effective. The weight of the evidence does not support the theory that MMR causes autism.î On April 23, 2001, the Institute of Medicineís (IOM) Immunization Safety Review Committee released a report that concluded scientific evidence did not support a causal relationship between the MMR vaccine and autism, noting that the vaccine ìhas been extremely successful in virtually eliminating measles, mumps, and rubella in the United States. Measles cases, for example, dropped from over 400,000 per year in the pre-vaccine era to only 100 in 1999.î (The institute is a private nonprofit that operates under a charter from the U.S. Congress.) The committee qualified its conclusion, however, and a summary of the report notes that the issue is not totally closed. ìThough the MMR-autism question might appear to be resolved, science is always a work in progressÖ. The committee acknowledges they could not rule out another possibilityóthat MMR vaccine could contribute to ASD [autism spectrum disorders] in a small number of childrenóbecause existing epidemiological tools may not have enough precision to detect the occurrence of rare effects like ASD,î the IOM report stated. ìAt present, however, no change of MMR immunization procedures is warranted.î The complete IOM report is available at http://books.nap.edu/html/mmr/reportbrief.html. óCarolyn Cosmos