Pro vs Con: Should We Immunize Our Children?
Two powerful arguments for an issue dividing the nation
It’s a decision that many new parents struggle with: To vaccinate or not? Everyone has an opinion on the subject, from pediatricians who refuse to see children who aren’t fully vaccinated, to parents who swear by the Dr. Sears Alternative Schedule, to those who won’t let a needle touch their little ones on religious grounds. But which is the right path for your family?
We asked folks on both sides of the debate to make their case. Dr. John Snyder, associate director of the Pediatric Residency Program at Baystate Children’s Hospital is on the pro side; that is, he thinks children should be vaccinated according to the schedule recommended by the U.S. Centers for Disease Control and Prevention (CDC). On the other side is Barbara Loe Fisher, president of the National Vaccine Information Center, a nonprofit she co-founded in 1982 to “prevent vaccine injuries and deaths through public education.” We asked both the exact same questions; their answers have been edited only for clarity and space. Give it a read, then head to the comments to tell us where you fall in this debate. Let the discussion begin:
Loop 21: How and why was the CDC/AAP/AAFP-recommended child immunization schedule developed?
John Snyder (PRO): The recommended schedule of childhood immunizations contains vaccines to prevent the most serious vaccine-preventable infectious diseases posing a threat to infants and children. Many of these diseases were true scourges of humanity in the not-so-distant past, killing or seriously harming large numbers of children every year. Because of these vaccines, many parents today have never seen or perhaps even heard of some of these diseases. Most pediatricians base their vaccine recommendations on those put forward by the CDC’s Advisory Committee on Immunization Practices (ACIP), which are usually echoed by the American Academy of Pediatrics (AAP) and the American Academy of Family Practitioners (AAFP). Before these recommendations are made, however, a vaccine must undergo a long and rigorous process of basic science and clinical trials, and subsequent FDA approval. These include:
Preliminary academic research
Three phases of pre-licensure trials which look at different aspects of the vaccine, from efficacy to safety
Post-licensure trials if the FDA approves the vaccine
Scrutiny by the ACIP, a panel of medical and public health experts (including virologists, infectious disease specialists, and epidemiologists) that weighs the safety and efficacy data as well as the public health ramifications for each vaccine, and advises the CDC on vaccine recommendations
The decision to include a vaccine in the recommended schedule of routine childhood immunizations involves close consideration of the public health benefits as well as the safety and efficacy data for that particular vaccine. The timing and frequency of doses is determined by a variety of factors, including when is the threat of the disease greatest, what is the efficacy of the vaccine at different ages, and how safe is it at that age.
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Barbara Loe Fisher (CON): A century ago, only one vaccine was recommended by public health officials and doctors and was mandated by states for children to attend school: smallpox vaccine, which was given to children at age 1. In 1949, the DPT (diphtheria, pertussis, tetanus) vaccine was licensed and five doses recommended for infants and children by the CDC and AAP. After that, the polio vaccine was licensed in 1955 and measles vaccine in 1963 and added to the list.
For the past 30 years, the CDC and medical trade associations, such as the AAP, have issued additional vaccine use recommendations for children following the licensure of new vaccines, including those for Hib, hepatitis B, chickenpox (varicella zoster), pneumococcal, rotavirus, hepatitis A, HPV, meningococcal and influenza.
The recommendations of federal health agencies and private medical trade associations, like the AAP and AAFP, serve as the basis for the creation of vaccine mandates in state public health laws, which require children to receive a certain number of doses of recommended vaccines in order to attend daycare, elementary, middle, high school and college. Today, the CDC/AAP/AAFP-recommended child vaccination schedule directs doctors to give children 69 doses of 16 vaccines between the day of birth and age 18, with 48 doses of 14 vaccines given between the day of birth and age 6.
Loop 21: Should all children be required to get vaccinated according to the recommended schedule? Why or why not?
Snyder (PRO): Immunizations have been called one of the greatest public health achievements in history. In the U.S., some vaccine-preventable diseases have been eliminated, and many nearly eliminated. Despite the overwhelming success of our vaccination program, it is extremely important that we maintain as high a vaccination rate as possible, because, until a disease is truly eradicated from the world (which has been achieved for only one disease--smallpox), people remain at risk. The “global village” in which we live makes a contagious child from anywhere in the word just a plane ride away. Outbreaks of serious diseases like measles and haemophilus influenzae type b, usually contained in this country by a high vaccination rate, have occurred when contagious individuals from other countries, where rates are lower, travel to the U.S. and infect susceptible people here. Unfortunately, we have seen this occur with increasing frequency as pockets of under-immunization have developed due to unfounded fear and mistrust of vaccines.
A concept that is often not well understood is that vaccination is important not just for the individual, but for the entire population. Herd immunity is the principle whereby vaccination of large numbers of people within a population can protect others in the population who either cannot receive an immunization or for whom an immunization is not effective (immunization failure). Some take this to mean that they do not have to get their child vaccinated because the “herd” will shield them from infection. This is a very dangerous strategy. An unvaccinated child is at risk of contracting vaccine-preventable disease from contagious individuals coming from both inside and outside of the community. But most importantly, the more people who decide to take this strategy, the lower our vaccination rate becomes. It doesn’t take much of a drop in the vaccination rate to produce outbreaks of disease.
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Fisher (CON): Parents of minor children, who are morally and legally responsible for protecting the health and wellbeing of their children and providing for their long term care if they are injured for any reason, should have the legal right to make the final decision about whether or not their children will use every government recommended vaccine according to the CDC’s schedule.
Like all pharmaceutical products, vaccines carry risks that can be greater for some than others because we are not all the same and do not all respond the same way to prescription drugs and vaccines, just like we do not all respond the same way to viral or bacterial infections. For example, the whole cell pertussis vaccine in the DPT shot, which was replaced in 1996 when a purified acellular pertussis vaccine (DTaP) was licensed and recommended by the CDC, caused a large number of minor and more serious reactions for some children, including brain inflammation and permanent brain damage. About one third of the more than 3,000 vaccine injury awards made under the National Childhood Vaccine Injury Act of 1986, which total nearly $2.5 billion as of September 2012, are for DPT vaccine-related injuries and deaths.
Vaccine mandates take a one-size-fits-all approach to vaccination, which does not acknowledge the fact that some children are more vulnerable to harm from vaccination. The legal right to exercise voluntary, informed consent to vaccination is a very important one to protect in America because Congress gave pediatricians legal protection from vaccine injury lawsuits in the National Childhood Vaccine Injury Act of 1986 and, in 2011, the U.S. Supreme Court declared vaccines “unavoidably unsafe” in order to completely shield vaccine manufacturers from product liability for the harm caused by vaccines.
The National Vaccine Information Center defends the human right of all citizens to exercise informed consent to medical risk taking, including the legal right of parents to make voluntary vaccination decisions for their children. NVIC advocates for the inclusion of flexible medical, religious and conscientious belief exemptions to vaccination in all health policies and state public health laws.
Loop 21: Why do you think vaccination is such a divisive issue?
Snyder (PRO): Clearly, parents want to do what is best for their children. Today, they must do so with an ever-enlarging volume of information coming at them from a huge number of sources. Often, emotional responses to scary information result in hesitancy or outright fear of vaccines, regardless of whether the information is scientifically sound. These messages, disseminated by anti-vaccine groups and sometimes by misinformed clinicians, can easily impart enough fear in a parent who is already confused by the multitude of information to hold off or delay giving their child a vaccine. The media perpetuates these myths by creating “false balance.” In other words, while there may be no scientific controversy on an issue like the MMR-autism linkage, the media will often present the issue as a controversy, as two equal and opposing viewpoints.
Many anti-vaccine proponents state that they are not anti-vaccine, but pro-safe vaccines, and that they are just trying to inform parents and protect children. Of course, this implies that vaccines are not safe, and that the CDC and doctors have other interests in mind. Many will state that the position of so-called mainstream medicine is closed-minded when, in fact, it is the anti-vaccine groups that are closed-minded. Their position never changes, no matter how much evidence contradicts their point of view or beliefs. They often claim that they have science on their side, though what they are really doing is misrepresenting the science or cherry-picking data from poorly conducted studies to support their firmly held beliefs. Those who use science to make truly informed decisions and recommendations are constantly open to the changes in knowledge that come from new scientific information. Science is all about openness to new information and change when indicated by the evidence. Ideologically driven movements, like the anti-vaccine movement, are all about belief and dogma and are unmoved by the evidence, no matter how elegant and robust. Unfortunately the real victims of all of this are the children, who are left vulnerable to easily preventable disease.
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Fisher (CON): The great divide in the vaccine debate today is between those who want the freedom to make informed, conscious vaccine choices, and those who believe that everyone should be forced to follow the doctor’s orders and adhere to one-size-fits all vaccine mandates. Mandatory vaccination proponents tend to downplay vaccine risks and maintain that unvaccinated children threaten “herd or community immunity” and transmit infections, which cause disease outbreaks. Voluntary vaccination proponents tend to emphasize vaccine risks and maintain that vaccine acquired immunity fails to provide long lasting immunity, pointing to disease outbreaks among fully vaccinated children. Both sides are sharply divided about whether enforcement of public health policy should trump the right of individuals to exercise voluntary, informed consent to medical risk-taking.
However, at the core of the heated and divisive debate about vaccination is fear of being harmed, either by an infectious disease or by vaccination. When health care debates involve choices that carry a risk of injury or death for us or our children, those debates are going to provoke strong intellectual and emotional responses based on our personal experience, knowledge, beliefs, and values.
The vaccine debate in the 21st century has also been influenced by the electronic communications revolution. Educated health care consumers, including young parents, are proactively doing their own research on the web today and what they learn prompts them to ask doctors more questions about vaccination and health. Many doctors are uncomfortable with this dialogue because they do not like the challenge to their previously unquestioned authority.
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The fact that the vaccine schedule has grown in the past 30 years from a recommended 23 doses of 7 vaccines by age six to 69 doses of 16 vaccines is one of the reasons a growing number of informed parents are asking questions about the quality and quantity of the scientific evidence used to support the safety of the vaccine schedule. Questions about the potential adverse effects that increased vaccination in early childhood may be having on healthy brain and immune function is being fueled by the unexplained dramatic increase during the past 30 years in the numbers of children suffering with chronic disease and disability: Today, 1 child in 6 in America is learning disabled, 1 in 9 has asthma, 1 in 88 develops autism, and 1 in 450 becomes diabetic. So many more parents today are questioning doctors about why they need to give their children so many more vaccines to stay healthy. This shift away from unquestioning use of government and physician recommended medical interventions, including use of more vaccines, is being replaced by consumer demand for the right to engage in critical thinking and make choices.
Loop 21: What should parents who are worried about vaccinating their children do?
Snyder (PRO): Avoid going to the Internet for answers, as many sites, while appearing to be authoritative and reliable, are often fronts for ideological anti-vaccine groups. Talk openly with your doctor about your fears and concerns, and ask about where to find additional sources of reliable information. Parents should follow the immunization schedule developed by the CDC and the American Academy of Pediatrics, which is designed by experts to ensure maximum protection and safety for children at various ages. You can find the schedule online at www.aap.org/immunization.
Fisher (CON): Knowledge is power. Becoming an informed health care consumer is about empowering yourself with information from many different sources so you can make an educated decision about if, when and how frequently your child will be vaccinated. After you have reviewed information about the complications of infectious diseases and the complications of each recommended vaccine, as well as spoken with one or more trusted health care professionals about the benefits and potential risks for your child, you have done all you can do as a parent to make the best decision you can make. NVIC’s downloadable “If You Vaccinate, Ask Eight Questions” is a quick guide to critical thinking about vaccination to help parents ask doctors questions before vaccination, including how to identify vaccine reaction symptoms.
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Loop 21: Are there any groups of children who should NOT be vaccinated according to the recommended schedule? Why or why not?
Snyder (PRO): There are very few contraindications to vaccination. However, there are some children who should not receive certain vaccines. Children who have congenital problems with their immune system should not receive the MMR and chicken pox vaccines. These are weakened live virus vaccines that could potentially cause illness in those who have severely compromised immune systems. Children with these problems are particularly dependent on the rest of us to be properly vaccinated, so they can be protected by herd immunity. Other people who should not receive the live virus vaccines are those on high doses of steroids for certain medical problems, and pregnant women. Children who have had life threatening allergic reactions to a vaccine should not receive that vaccine in the future. This is an extremely rare occurrence.
Fisher (CON): As an informed health care consumer, it is important to fully understand the benefits and risks of use of one or more vaccines for your child before vaccination takes place. Vaccine manufacturers and the CDC list contraindications (reasons to not give a vaccine) and warnings/precautions for use of different vaccines. However, not all doctors are aware of or follow contraindications and precautions to vaccination, which is why parents must be informed and find a doctor they can trust, who will work with them as a compassionate partner in making vaccine decisions that includes taking steps to prevent serious vaccine reactions.
Recognizing the signs and symptoms of vaccine reactions, can help parents identify vaccine reaction symptoms that may require immediate medical attention and help parents work with their doctors to make sure more vaccinations will not cause more serious reactions or permanent health problems. Parents should be aware that it is the legal duty of pediatricians and all vaccine providers to:
Provide written vaccine benefit and risk information to the parents of a minor child or adult before a federally recommended vaccine is given;
Keep a permanent record of all federally recommended vaccinations administered, including dates and doses of vaccines given; the manufacturer’s name and vaccine lot number; and the name, title and address of the vaccine provider;
Record in the permanent medical record symptoms of serious health problems, which occur after federally recommended vaccines are given to a child or adult, many of which are described in the law’s Vaccine Injury Table;
Report symptoms of serious health problems, which occur after a federally recommended vaccine is given, including hospitalizations, injuries and deaths, to the federal Vaccine Adverse Events Reporting System (VAERS).
It is a good idea to ask the person giving your child vaccines to give you a copy of this information the day vaccination takes place so you will have a permanent record.
Loop 21:Are alternate schedules that spread out or skip vaccinations a safe compromise? Why or why not?
Snyder (PRO): The timing of the vaccines and the schedule of doses is designed to confer the highest degree of protection to infants and children when their risk is greatest. It takes into consideration both safety and efficacy, and is informed by the best available scientific evidence. This data is constantly reviewed and changes are made when warranted by new evidence. When parents make changes to this schedule, whether by delaying or spreading out immunizations, or by avoiding certain immunizations all together, children are put at risk for contracting serious and preventable diseases. Many parents have been led to believe that a spread-out vaccination schedule is somehow “safer” than the one recommended by the CDC. Some of this comes from “how-to” style books, even some written by pediatricians. If there are parents out there who are considering altering the schedule, I recommend they read my review of one such popular fear-spreading book.
Fisher (CON): There are many biological, genetic, environmental and other co-factors that may raise or lower vaccine risks for an individual child. As a consumer-led organization, NVIC does not give advice about vaccine schedules but encourages well-informed vaccine decision-making, which also includes a discussion about the pros and cons of vaccination for a child with one or more trusted health care professionals. If a doctor refuses to discuss vaccination with you or respect the vaccine decisions you have made for your child, it is important to search for a doctor who will work with you and respect your choices. At the end of the day, it is you and your child, not your doctor or state health official, who will personally live with the consequences of the decision you make.
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Loop 21:Is there anything else our readers need to know about immunization?
Snyder (PRO): As the diseases that were once commonplace causes of childhood suffering and death have faded from memory, fear of the vaccines themselves have taken their place. These fears, however, are unwarranted. Though we can trace the complex routes of these fears, they are not based in scientific fact. The truth is that immunizations remain an extremely safe and hugely important preventive health measure. They are perhaps the single most important and effective way of protecting your child from harm that we have. I plead with parents to let reason and level-headedness prevail when confronted with the onslaught of information they encounter about this subject. Speak with your doctor, and let the experts inform on this critical issue.
Fisher (CON): There is a national Vaccine Injury Compensation Program that was created under the National Childhood Vaccine Injury Act of 1986, that parents should be aware of in the event their child suffers a permanent health problem related to vaccination.
Do you support childhood vaccinations? Tell us in the comments.
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