From Red Flags 24 August 2005:-
Vaccinate Johnny To Protect Grammy — And Other Wild Ideas
By Red Flags Columnist, F. Edward Yazbak, MD
There is a new concept in vaccination practices these days. If for some reason you cannot vaccinate group A — or if such vaccination is not effective — then vaccinate group B instead.
This notion was illustrated in a remarkable statement by Stephen Cochi, acting chief of the National Immunization Program (NIP) at the Centers for Disease Control and Prevention (CDC), in response to the good news survey discussed in “Trust Me. I Have The Statistics” (1)
Cocchi told the Associated Press, “With more toddlers than ever being protected, the CDC reminded parents that adolescents need their shots, too. Among them, a new whooping-cough booster shot for teenagers and pre-teens was approved earlier this year to combat a return of that disease as childhood vaccine protection wanes …That booster dose is crucial because, while whooping cough seldom kills older children, it can be fatal to newborns who haven't yet started their immunizations. Already this year, 15 infants have died from whooping cough.”
So now, after succeeding in protecting toddlers, the CDC was recommending vaccinating adolescents and young adults in order to protect small infants — still too young to be vaccinated — from the whooping cough?
This reasoning — though unreasonable for most — is defended by the “experts.”
A similarly dubious argument resulted in an ill-advised situation in 1991, which is still with us to this day. The CDC, on the advice of the advisory committee on immunization practices, decided that giving the hepatitis B vaccine to infants who did not need it, starting hours after birth, was a wonderful idea — even though it was well-known that the acquired immunity would not last until the age of “risk-taking,” when they would be likely to contract the disease.
Many parents of children with autism remain convinced that hepatitis B vaccination was responsible in part for the increase in autism in the 1990s and argue that this was partly due to the fact that the vaccine — only available in single-dose vials — still contained 12.5 µg of ethyl mercury per dose.
Between 1990 and Dec. 31, 2004, there were 44,245 reports to the Vaccine Adverse Events Reporting System (VAERS) of reactions following the administration of Hepatitis B vaccine, alone or with other vaccines. There were 16,853 emergency room visits, 3,483 hospitalizations and 865 deaths, including 37 reported deaths of vaccinated infants, who were less than a month old and did not, therefore, receive other vaccinations at the same time.
The rationale for the recommendation is explained in an official document on one of the CDC’s Web sites. (2)
Question 5: Why not vaccinate children in those families where there is the highest risk of HBV [hepatitis B virus] infection, rather than vaccinating all infants/children?
Routine immunization of infants and adolescents is recommended for several reasons. One is that there is a large disease burden attributable to HBV infections that occur among children. Approximately 30,000 infants and children were infected each year before routine infant hepatitis B immunization began and CDC estimates that one-third of the chronic HBV infections in the United States come from infected infants and young children. The majority of these infections occur among children of mothers who are not infected with HBV and thus would not be prevented by perinatal hepatitis B prevention programs. Other than for infants born to HBV-infected pregnant women, there is no way to identify and selectively vaccinate those children at risk of infection (Margolis, 1991).
Another reason we vaccinate infants and older children is that it will provide them protection against exposure to HBV infection when they are older adolescents and adults. While most HBV infections occur among older adolescents and young adults, vaccination of persons in high-risk groups has generally not been a successful public health strategy. In addition, about 30 percent of persons do not know where they acquired their acute HBV infection (Alter, 1990).
The CDC infatuation with round figures with many zeros — particularly with numbers in the 30,000 range was discussed in “Trust me.” (1)
The American Academy of Pediatrics (AAP) 2003 Red Book, the official pediatric infectious disease reference, states on page 320: “During the 1980s, before implementation of routine childhood hepatitis B immunization, an estimated 16,000 children (younger than 10 years of age) were infected each year. The highest risk of early childhood transmission is among children who immigrated to the United States from countries where HBV infection is highly endemic (e.g., Southeast Asia, China). (3)
Supposing that those estimates were close to being realistic, who should we believe?
The CDC’s 30,000 cases without ethnic identification?
The Red Book’s 16,000 infants and children under 10, mostly from Asia?
One way to find out for sure is to go to the CDC’s own reference on the subject.
The chapter on hepatitis B (pages 223 to 245) in the 1999 Pink Book, the official CDC reference, does not mention figures for infants and children who are not born to infected mothers, but it does mention, on page 230, the total number of reported cases. “The incidence of reported hepatitis B peaked in the mid-1980s with about 26,000 cases reported each year. Reported cases have declined since that time and fell below 10,000 cases for the first time in 1996. In 1998, a provisional total of 8,651 cases were reported.” (4)
So now, who and which figures should we believe?
The CDC’s Web site, intended for public consumption, which says that before 1991, there were some 30,000 infants and children infected each year?
Or the official CDC reference intended for doctors and other health professionals, which states that for all age groups, the largest number of hepatitis B cases ever reported in one year was about 26,000 cases.
In addition, if there were, indeed, about 26,000 new cases of hepatitis B viral infections in all age groups during a record year, then it would be highly unlikely that 16,000 infants and children under 10 would be infected each and every year, as claimed in the Red Book.
Everyone agrees that infants born to hepatitis-B-infected mothers or to mothers with positive or unknown hepatitis B serology should receive the appropriate dose of the specific immune globulin and the first dose of hepatitis B vaccine immediately after birth as recommended. These infants are then to get a second dose of vaccine a month later and a third, five months after that.
What was, and remains, ill-advised is the recommendation to administer the hepatitis B vaccine to all newborns, infants and children whose mothers were tested and found to be negative and who do not belong to high-risk groups because of ethnicity.
Yet, since 1991, that is exactly what we have been doing. We have been administering the hepatitis B vaccine to all infants and children mainly because we never succeeded in convincing adolescents and young adults — who actually needed the protection — to get vaccinated.
The final argument presented by the CDC on its Web site is that all infants should receive the hepatitis B vaccine starting at birth because 30 percent of affected adults do not know how and where they acquired the disease. This argument has been, and will remain, the most preposterous reason ever for a pediatric vaccine mandate. It made as much sense in 1990 as the recent idea to vaccinate teens to protect infants from whooping cough.
There is, in fact, one way and only one way to find out that 30 percent of individuals with acute hepatitis B viral infection in the United States do not know where they acquired the disease — if that statistic is correct:
Someone had to ask them.
The telephone call might have gone something like this: “Hi, I am Mary and I am calling from the department of health. Are you able to talk in privacy?
Mary: We have been notified that your blood test was positive and that you have Hepatitis B.
Patient: You have?
Mary: Yes and we are trying to determine where and how you could have been infected.
Patient: You are?
Mary: Yes. Let me first reassure you that your responses will be kept in strict confidence.
Patient: Th-Thank you.
Mary: Your honest answers to three simple questions will actually help the CDC make important decisions relative to the vaccination of newborns and infants against Hepatitis B — nationwide.
Patient: My answers?
Mary: Yes. I also want to assure you that your name, address and phone number will not be sold to any mass mailing list. We don’t do that at the department of health.
Patient: Thank you. I … I really appreciate that. I get so much junk mail already and all these people calling around supper time.
Mary: You are welcome. Are you ready? Can we start?
Mary: Here are the three questions. Are you a male/female prostitute with multiple partners who does not use protection? Did you have unprotected sex recently with a strange woman or man who is not your spouse? Do you use intravenous drugs and share needles with friends and neighbors?
Patient: Uh …Uh …No.
Mary: To all three questions?
Mary: So you have no idea why your test for hepatitis B was positive?
Patient: No … No. I really don’t.
Mary: Thank you. You will be added to the 30-percent group who has no idea where and how they were infected.
Patient: The 30-percent group?
Patient: Are you telling me that 70 percent of the people you call actually answer “yes” to one or all of these questions?
Mary: Yes, believe it or not. But it is the 30-percent group that is really important to us. Thanks to people like you, we will soon be vaccinating all newborns.
Patient: You will?
Mary: Well, we have failed to convince adults who really need the vaccine — you know what I mean — to get it and so, with the help of the 30-percent group, we will now be able to appropriate funds and convince everyone that it is imperative to vaccinate all the infants and children starting in the nursery.
Patient: In the nursery?
Mary: Yes. The CDC believes in complete protection — from the womb to the tomb.
Patient: Uh … huh.
Mary: You should be proud of your contribution to the health of a whole generation. Have a good day and thank you for your help.
Patient: You’re welcome. Bye.
The incidence of hepatitis B viral infections has decreased nationwide because of needle-exchange programs, the fear of AIDS and public education. Monogamous relations are more common and promiscuous adults are much more careful now. Even intravenous-drug users have realized that it is not worth dying for a fix. Yet, since 1991, when we started vaccinating infants and children against hepatitis B, vaccination rates of adults have remained dismal.
The following is the CDC summary update of April 1, 2005 (54(RR05); 1-11 MMWR).
“An estimated 1.0 to 1.3 million persons in the United States are chronically infected with hepatitis B virus (HBV), of whom approximately 5,000 die of HBV-related cirrhosis or liver cancer each year. Risk conditions for hepatitis B include occupational exposures and risk behaviors (e.g., injection-drug use and multiple sex partners). Although reported cases of HBV declined 76 percent during 1987-1998, the annual number of new infections remained substantial with 78,000 cases estimated in 2001. Despite the availability of an effective vaccine, vaccination coverage rates remain low in the majority of targeted populations. In one study, nine percent of men who have sex with men had both a history and serologic evidence of hepatitis-B vaccination in 1998. Among injection-drug users attending a sexually transmitted disease clinic in San Diego during 1998-2001, vaccination coverage for hepatitis B was six percent.”
Describing vaccination rates of six and nine percent in targeted populations as just “low” shows how important positive thinking is – if one is a CDC epidemiologist. What would be hard to explain is how over 90 percent of IV-drug users and promiscuous homosexuals will benefit because their neighbor’s baby will receive a vaccine before he is 24 hours old — and often before he has even voided for the first time.
In the “Flu Vaccine Saga: The Latest Twist,“ (5) I reviewed the findings of a study by the National Institute of Allergy and Infectious Diseases (NIAID) that was published in the Archives of Internal Medicine. (6)
The NIAID researchers carefully and methodically estimated influenza-related deaths — and all deaths — among the elderly in the United States during 33 consecutive flu seasons between 1968 and 2001.
They noted that:
For people 85 and older, the mortality rate did not change throughout the 33 annual flu seasons
In those 65 to 74 years of age, the mortality rate remained the same between 1980 and 2001
The “flu-related mortality” in the elderly remained always less than 10 percent of the total number of winter deaths.
In an interview, the lead author stated that the dramatic increase in vaccination coverage among the elderly should have led to a dramatic drop in flu deaths. "This is not what we found … So the mortality benefits are probably very much overestimated," she said.
All this did not sit well with the CDC experts, who for 30 years had recommended yearly flu vaccination. They promptly disagreed with the NIAID findings in the press and cited the ever-popular “30,000 to 36,000 flu deaths” a year. (7)
The study’s lead author stood her ground: The flu vaccine — if administered to the elderly — does not decrease the influenza mortality among them but if we were able to vaccinate 70 percent or more children of school age, then we would indirectly be protecting the elderly better than if they were vaccinated.
The CDC liked that idea a lot and reminded everyone that children and infants starting at the age of six months should receive yearly influenza vaccinations.
To secure even better protection of the elderly, the agency and HHS (the U.S. Department of Health and Human Services) also helped draft recent legislation (Federal Register: Aug. 15, 2005 Vol. 70, No. 156) that would require all nursing homes receiving Medicaid or Medicare dollars to provide all residents with an annual flu vaccination unless such vaccination is contraindicated or specifically refused. (8)
Parents who questioned why babies needed the rubella vaccine at the age of 12 months were told that it was because the children, if unvaccinated, could later come down with the disease and expose their pregnant mothers or first-grade teachers.
A more reasonable recommendation was to make sure that all health-care workers potentially in contact with pregnant women be rubella-immune or re-immunized.
A1981 CDC study revealed that health workers were not eager to comply:
Only 50 percent of susceptible clinical employees in a large medical centre showed up for their recommended booster rubella vaccination and just one of 11 rubella-susceptible obstetricians-gynecologists received the vaccine. (9)
* * * *
So, what is more absurd?
Vaccinating teens to protect infants who are too young
Vaccinating infants because adults at risk refuse to be vaccinated
Or vaccinating children because the vaccine does not seem to affect the mortality rate in the elderly.
You tell me.
Red Book, 26th Edition, American Academy of Pediatrics Committee on Infectious Diseases. Larry K. Pickering MD, FAAP, Editor
Atkinson W, Humiston S, Wolfe C, Nelson R, Editors. Epidemiology and Prevention of Vaccine-Preventable Diseases, 5th Edition, Centers for Disease Control and prevention.
Simonsen L, Reichert TA, Viboud C, Blackwelder WC, Taylor RJ, Miller MA. Impact of influenza vaccination on seasonal mortality in the U.S. elderly population. Arch Intern Med. 2005 Feb 14; 165(3):265-72.
Orenstein WA et.al. Rubella vaccine and susceptible hospital employees. Poor physician participation. JAMA 1981 Feb 20; 245(7):711-3