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Reasons Why People Choose Not to Vaccinate |
 Dr Sue Page
Vaccination has probably saved more lives worldwide than any other single medical intervention. In 1803, just five years after the publication of Jenner’s monograph, the first smallpox vaccine was imported into Australia. By 1847 it was being produced in Sydney, and after typhoid vaccines were shown to be effective during the Boer War, several laboratories were set up around Australia. Limited shipping led to a shortage of the diagnostic agents and antisera during WWI and in 1915 the Federal government established what is now the Commonwealth Serum Laboratory in Melbourne.
Remembering nothing is 100% safe, nor 100% effective, in nearly 200 years the safe effectiveness of vaccination in reducing the severity and incidence of deadly disease has been proven many times (for example, Galazka 1984, Velmirovic 1991, Koplan 1985). In 1987 Holden et al calculated the benefit : harm ratios for each of the major vaccines, and found the overall a “typical program” of immunisation in a developing country could prevent 45 deaths and 12 serious handicaps per month, while causing 1 death every 22 years and 1 serious handicap every 7.5 years.
So, if Australia was so fast off the mark in recognising the benefits of vaccination, why did the rate drop so low in the 1990s?
The Wallis group study in 1995 looked at 1000 families with children aged 0-5 years, and found 97% supported vaccination. The following year, Roy Morgan Research found 96% of 503 parents surveyed thought that their children were already fully vaccinated, despite ABS figures that only 53% were registered as fully vaccinated.
This means the vast majority of children not fully vaccinated probably just need the ACIR reminder system. A significant number were children of single-parent, low income families with more than three children, particularly if the family has a history of continual minor illnesses. It is logical to assume these families would be assisted by more easy access to vaccination centres such as mobile clinics.
Statistically, we should all be able to achieve vaccination rates of around 97% fairly easily. The latest national figures (Sept 2000) show 91.3% of children 12-15 months and 85.09% of children 24-27 months are fully immunised for their age. Latest ACIR data for this area (June 2000) puts the Northern Rivers division at 76.4% and the Tweed Valley division at 80.8% overall. The ACIR paperwork now attracts its own rebate, and the consequent greater accuracy in recording shows some practices have rates of 100%.
The fact remains, though, that a significant number of Australian children are not being vaccinated because their parents have chosen to deny them the opportunity.
When I first moved to the Far North NSW Coast, I did not realise I was moving to the home of Australia’s anti-vaccination organisation. We had one-tenth the total population of NSW, but the lowest rate of vaccination. Consequently, we had the highest rate of vaccine-preventable disease, with one-third to one-half the NSW total cases occurring in our region alone. In case you think this reflects poor hygiene in Nimbin-style communes, we only had one-tenth of the gastroenteritis and salmonella cases, or our fair share.
In the University of Sydney study published in ANZ Journal of Public Health, 1998, Professor Simon Chapman found people who oppose immunisation usually do so because of their views of the way doctors and drug companies operate, rather than an assessment of the facts. I agree, and discovered early on that non-vaccinators can be considered as two distinct groups of parents.
One group are the true conscientious objectors and their views are not going to be changed by quick debate. Often their own children have had some form of an adverse reaction, and they have manifested a basic distrust of doctors by seeking alternative health care. They are frequently educated and articulate people, and with sufficient time on their hands to read the internet and libraries avidly and to mount strong community campaigns.
Research shows they believe any or all of the following: that the immunisation program is an exercise of the power of medicine and the government authorities in society and they strongly oppose any infringement of civil liberties such as compulsory vaccination through schools; that drug companies are greedy multinationals who pay to have things covered up; that there is a conspiracy between drug companies, doctors, and the government; that even WHO receives funding from pharmaceutical companies, so it can’t be trusted; that the drugs themselves contain poisons and impurities and cause new diseases because they go against nature and are essentially evil; and that safe alternatives exist that are not being researched for financial reasons. They make emotional appeals that are difficult to oppose because they feed into common parental anxieties and mount strong community campaigns against vaccination. These are the parents for whom the conscientious objectors' ACIR forms were made.
Unfortunately they are good at spreading their message: Gangarosa et al, Lancet 1998, looked specifically at the effects of the anti-vaccination movement on rates of pertussis vaccination and disease. The evidence was clear that pertussis incidence was 10-100 times higher in countries where immunisation programs were compromised by anti-vaccine movements, than in neighbouring countries where high vaccine coverage was maintained.
In my experience, the larger group of non-vaccinators are parents who have been influenced by these views without having the time to fully research the information themselves, and this is the group you can help the most time-efficiently by reality checking their beliefs.
It should be realised that anti-vaccination organisations can make themselves sound appealing and may not be obvious in their intent. The Australian national body used to list itself under 'Medical Practitioners' in the phone book, and has also advertised itself as being a hotline to collate information about adverse reactions to vaccines.
The first step in the consultation is to ask if the parents have a particular reason why their child is not vaccinated. This helps you quickly decide the extent of their belief. Health professionals, who regularly assess the reliability and integrity of the information they read, will know the difference between double-blind placebo cross-over trials and retrospective anecdotal data. To help these parents, we need to recognise the grain of truth behind each of their beliefs, and use our relationship with our patients to guide us into presenting the counter evidence in an appropriate manner.
So what are the main components of the anti-vaccination argument?
The diseases are simple childhood illnesses
The evidence is against this.
Between 1978 and 1993 there were 227 Australian deaths due to vaccine-preventable illnesses, 165 of these from measles. In 1989, 1.5 million people worldwide were killed by measles.
Measles
Measles is a highly contagious illness, and more than 90% of unvaccinated people are likely to catch it before they are 20. It is easy to be complacent about something so familiar, but the facts are:
- Case fatality 1 in 5-10,000
- SSPE 1 in 25-100,000
- Hospitalisation 1 in 70
- Encephalitis 1 in 1000
- Seizures 1 in 200
- Pneumonia 1 in 15
- Otitis Media 1 in 10-20
Remember subacute sclerosing panencephalitis is universally fatal, and the encephalitis group has a mortality rate of 10-15% and 15-40% permanent brain injury.
Pertussis
Pertussis is a severe illness with paroxysmal coughing lasting from 4 weeks to 2 years, but is considerably more severe in infants younger than one, due to their smaller airways and tidal flows.
Case mortality
Overall 1 in 200-1000
Infant 1 in 200 (1)
Hospitalisation
Overall 1 in 3
Infant 3 in 5
Encephalopathy
Overall 1 in 1500
Infant 1 in 100
Seizures
Overall 1 in 50
Infant 1 in 50
Pneumonia
Overall 1 in 30-40
Infant 17 in 100
Hib
Hib used to occur in 1 in 200 Australian children less than five years. It causes a variety of serious illness including epiglottitis, septicaemia, cellulitis, pneumonia, septic arthritis, osteomyelitis, and pericarditis.
60%, or nearly 2/3 of reported Hib invasive disease is meningitis, and this accounts for 90% of all bacterial meningitis in the under 18 month age group. 1 in 20 of this group will die, with a further 15-45% having long term disabilities including cerebral palsy, deafness, convulsions, and intellectual impairment.
Case fatality 1 in 20-50 cases.
Polio
Paralysis and severe pain occurs with 1 in 1000 childhood and 1/75 adult polio cases. Half these remain permanently paralysed, many of the others develop post-polio syndrome years later.
Rubella
Rubella during the first trimester of pregnancy causes 90% of infants to develop multiple defects including deafness, blindness, cardiac malformations, and mental retardation.
Mumps
15% of mumps cases develop meningitis, usually self-limiting, and 5/1000 encephalitis. 1-5/100,000 remain permanently deaf. 15% of cases occur in the older age group, where 1/5 of the males can develop orchitis, and some of these sterility.
Diphtheria
Before vaccination was available, diphtheria used to kill a similar proportion of the population each year as the road toll does today.
Reported cases
From 1992 to 1994 there were nearly 32,000 cases of notified vaccine preventable illness in Australia. With under-reporting, the real incidence may be up to 10 times higher.
Pertussis 10,114
Hib 1,071
Measles 10,579
Rubella 10,148
The risks of vaccination are concealed
There is some evidence to support this view. Serious adverse reactions are required to be reported for all medications, where 'serious' is defined as significantly affecting a patient’s management, but historically all the reports to ADRAC come from just 10% of doctors, and only 1% surveyed knew about the (optional) separate reporting line for vaccines.
For vaccination, as the effects can occur after a time interval (eg MMR meningitis 15-21 days later) the Commonwealth is interested in events occurring within 30 days of vaccination, unless clearly not associated (eg. motor vehicle accidents), especially death, danger to life (eg. anaphylaxis), hospitalisation, prolongation of hospitalisation, temporary interruption of normal activity (eg screaming >3hours, shock-like collapse, convulsions, encephalopathy, flaccid paralysis), birth defects.
There have been clear attempts to advertise the known risks: the Government's “Understanding Childhood Immunisation” discusses the common and also the serious side effects encountered, and to date more than 650,000 copies have been distributed.
Another government publication easily available is Immunisation, Myths and Realities. For interest, the adverse reactions published as a result of the recent schools-based MMR campaign were a total of 61 reactions from 1,225,249 vaccinations given. These included 18 faints, 19 syncopal fits, 5 anaphylaxis, 3 hyperventilation and 3 rashes.
The vaccines are ineffective, rates fell for other reasons
This is a commonly used argument to minimise perceived risk. The usual graphs show death rates, which are largely influenced by antibiotics, intravenous hydration, intubation and ventilation in intensive care units. In contrast, the rates of incidence have all only fallen dramatically within months of the appropriate vaccine being made available. As recently as 1988 WHO sponsored a mass polio vaccination drive and since then there has been a 75% reduction in polio deaths worldwide.
Another commonly used argument is to point out how many of the children in any given outbreak are vaccinated. This is a fallacious argument as the importance is in relative risk and not in total numbers. For example, measles vaccine is 95-98% effective, and the virus is 99% contagious, so in an epidemic the risk to a vaccinated child is 5%, and to an unvaccinated child is 99%. Most children are vaccinated, so the 5% clocks around pretty fast, and if 30 children are sick in a school it may well be that half of them are vaccinated. If we had 100% vaccination rate the only children to acquire measles would be this vaccine failure group. This would not mean that vaccination is ineffective, any more than it would that vaccination causes measles.
Vaccines can cause disease
Vaccines are able to create many of the problems associated with the illnesses themselves, but at much lower rates. For instance, live oral polio vaccine causes paralysis at a rate of 1-3/million doses, the risk being highest with the first dose. It can cause paralysis in unvaccinated contacts at a rate of 1/million doses (seven cases a year in the US), so should not be given in households where someone is immuno-suppressed.
Encephalitis may follow measles vaccination at a rate of 1/1-3 million doses.
It is not permanent, and may not be causal.
One early strain of mumps vaccine was found to cause a transient encephalitis 1/300 and this Urabe AM-9 strain was withdrawn in 1992.
The notion that pertussis vaccine could cause permanent neurologic damage was first aired in the 1940s, but no specific syndrome has been described and the evidence does not support a clear causal relationship with DTP. The Institute of Medicine of the US National Academy of Sciences has twice reviewed the evidence on long-term neurological damage and has concluded:
1. Children who experience a severe neurologic illness within 7 days of receiving DTP vaccine are at increased risk of developing long-term neurologic damage or death, but this is rare: between 0 and 10.5/million doses.
2. Children who do not experience a severe neurologic illness within 7 days are not at long-term risk of nervous system dysfunction.
Vaccines contain dangerous chemicals
It is true that vaccines contain dangerous chemicals, mostly in doses thought to be too small to be of concern.
Aluminium hydroxide is added to some vaccines as an adjuvant to promote earlier and more potent and persistent immune responses.
Formaldehyde is used to inactivate bacterial products for toxoid vaccines.
Neomycin is used to prevent bacterial overgrowth. It replaces the earlier use of penicillin.
Merthiolate (thiomersal), however, is used in more than 30 vaccines, including Hep B, DTP, and Hib. Mercury levels in small babies given multiple vaccines at one visit have been found to exceed USA Environmental Protection Agency limits. FDA now recommends first dose Hep B be withheld until the baby is 2-4 weeks old, and that vaccine companies look to producing mercury-free alternatives. [Ed note. Vaccines listed in the Australian Vaccination Schedule for Children have not contained thiomersal since 2000. All childhood vaccine stock in circulation is thiomersal free.]
Vaccines contain blood and animal products that can transmit disease
Early batches of polio vaccine (OPV & IPV) were contaminated with SV-40, which is resistant to formaldehyde, and which is known to cause cancer in rats. By 1961, 80-90% of all US children younger than 20 years had been injected with contaminated vaccine. There is no evidence that SIV contamination occurred, and follow-up has failed to show any significant increase in the rates of brain, bone, and lung cancers. The same batches were used in Belgian Congo (high incidence of HIV), and Poland (lowest rate of HIV in Europe)
Reverse transcriptase is an enzyme necessary for retroviruses to reproduce, and has been found in measles, mumps, influenza, and yellow fever vaccines. However, it causes no known harm, and is not a marker for contamination by the retroviruses themselves, including HIV.
Bacteria for some vaccines is grown on a culture of bovine heart and brain components. While the current Hib and MMR vaccines available are sourced from bovine spongiform encephalopathy free areas, it is also likely the risk of contamination is theoretical only.
CJD has not been reported despite 569 million doses of vaccine given worldwide since 1971, nor has CJD been reported to be transmitted to 158 recipients of blood from donors later found to have the disease.
The rubella part of MMR is a live virus originally cultured on cell lines of aborted foetuses. However, through the process of repeated cultivation over the 30 years the cells have become genetically uniform and unlike 'wild' cells. Varicella vaccine is also grown on a human diploid cell line. These vaccines are not banned by the Catholic or Jehovah’s Witness organisations.
Vaccines damage the immune system, including causing allergies
Some vaccines have allergy precautions, eg. MMR is cultured on chick fibroblast cell culture. However nearly 500 children with egg anaphylaxis were vaccinated at Sydney Children's Hospital with only three reactions reported, and only one of these requiring adrenalin.
There is no evidence of increased allergy long term after immunisation.
Several studies have looked at the incidence of asthma following vaccination with no clear association found. The NZ study, Kemp et al 1997 looked at 1207 children, but only 23 were unimmunised. While an association was found between asthma diagnosed by age 10 and DTP vaccination before 15 months, the statistical significance rested on one child.
A prospective trial of 669 infants assigned to receive one of three types of pertussis vaccine or placebo found no differences in subsequent atopy in the four groups, but found 40% of those who contracted pertussis became asthmatic.
Vaccines cause SIDS
Sudden infant deaths have been reported as far back as 3000 years, well before vaccination began, but it is easy to see how a temporal connection is made. Most SIDS occur in the first six months of life, and by definition 50% of these will be within one month of a vaccination dose. However, there are several studies showing no statistical correlation, including 130,000 children in USA (Griffin, NEJM 1988), over 10,000 in England (Pollack 1984), and 400 SIDS children in USA (Hoffman, Paediatrics 1987)
Two Australian studies both showed that SIDS children were more likely to be not vaccinated (63% in the SA series) or undervaccinated (50% unvaccinated, 25% undervaccinated in the WA series).
The claim I probably most take exception to, though, is: “In 1975 Japan raised the minimum vaccination age to two years; this was followed by the virtual disappearance of cot death and infantile convulsions.” AVN Newsletter.
Actually it remained at 1.2 per 1000 live births, and more children died of vaccine-preventable illness (pertussis deaths < 1yr were 4 per 100,000 in 1970, and rose to 20 per 100,000 in 1984), so vaccination was reintroduced at 6 months. What did fall was the rate of compensation payments to parents of SIDS children, as described by Noble, Journal Am Med 1987, and Cherry, Paediatrics 1988.
The rate in Australia was 2 per 1000 live births until 1988 when parents were advised to put their babies to sleep on their backs. Within 12 months the rate fell to 1.1 per 1000. In SA this coincided with an increase in vaccination rates.
Vaccines cause chronic illness
Arthritis: Some vaccines cause transient joint pains (such as measles arthralgia 0-0.3% infants, 23% women over 30 years) but true arthritis, and auto-immune illnesses such as SLE, are not increased by vaccination. Multiple sclerosis sufferers can trigger a relapse if vaccinated, but the rate of developing MS is not changed.
Inflammatory bowel: The Lancet published a case series in 1998, suggesting a temporal association between parental recall of MMR vaccination and a new syndrome of an unusual type of inflammatory bowel disease with pervasive developmental disorder. However, vaccine virus was undetectable in the bowel, or CSF of any of the subjects, and selection and recall biases were apparent.
Of concern is that the mean age of children when their parents first report concerns over developmental milestones is 18 months, and MMR is given 12-15 months. Follow-up research by the Akita University in Japan found no evidence to link vaccination with MMR and Crohn’s disease, and alternative theories include exposure to MAP (Mycobacterium Avium subspecies Paratuberculosis) through milk and water.
Autism: Taylor et al, Lancet 1999 gave British data to show a rise in the incidence of autism that preceded MMR by 10 years, with no 'step-up' when vaccination was introduced in 1988. This, and other studies, have failed to show a statistical difference in autism rates for vaccinated vs not. In USA, no cases of autism were notified within 28 days of DTP despite a total of 80.1 million doses given 1978-1990. [Ed. note: Please see updated research under Frequently Asked Questions on the "Vax 'em!" website.]
Diabetes: NIDDM in American adolescents aged 10-19 has increased tenfold in little more than a decade. This is likely due to the significant increases in obesity, with consequent effects on insulin resistance.
Cancer: Rates after vaccination can be lower, such as liver cancer following hepatitis B vaccination.
Natural remedies and being healthy can protect my child
Clearly, if clean air, organic food, avoidance of chemicals, and healthy lifestyle were truly protective, our region would have rates of illness lower than inner-city Sydney, not higher. For the remedies themselves, most have not been formally tested, or have been tested and found to be ineffective, and often have the added disadvantage that they contain 'mystery' ingredients in variable doses. Most do not have adequate toxicology studies for adults, let alone children, and they often require multiple and complex dosing regimes (eg 23 oral doses given over 24 hours to a child age 5 years, Sulfaro, MJA 1994.
There is no statutory body governing homeopathic remedies, so practices can vary. However the major homeopathic societies of New Zealand, England, and Australia do not support the use of homeopathics as an alternative to conventional vaccines, but endorse their use to 'boost' the immune system of the person to be vaccinated.
“There is at present no scientific evidence that these confer immunity in the same way as vaccines, and the society does not recommend to members, or anyone, that they should use them instead of the allopathic (conventional) vaccines. Anyone who does so is taking the responsibility upon themselves, and must recognise the risk they are exposing themselves to.”
NZ Homeopathic Society President 1988
Vax to the future
Varicella zoster vaccine is already available in Australia, and rotavirus and herpes simplex II vaccines are being trialed. Meningococcal vaccine can be used for outbreak control in adults, but is ineffective in the under-2s. [Ed note: See updated information on the new meningococcal vaccine for children in the Diseases chapter on the "Vax 'em!" website.]
] HPV trials will begin shortly, and research continues for vaccines for HIV, Hep C, and malaria.
In the next few years we are going to see a whole new crop of vaccines, thanks to genome research. Perhaps the most exciting are the immunogens that can be administered to nasal, vaginal, or oral mucosa. One example is the recent development of an oral tetanus vaccine formed by inserting the DNA code for tetanus toxoid into an attenuated strain of salmonella.
Another option is genetically modified vegetables and fruit. Not only can plants be produced that are resistant to viruses, insects, and herbicides, but research is already underway to produce heat-stable, multicomponent, orally administered vaccines. In 1992, Arntzen et al described a tobacco plant that expressed 0.01% of its total protein as the surface envelope glycoprotein of Hepatitis B, which was used to immunise mice. Potato, tomato and lettuce plants have been able to produce Norwalk viral capsid protein. Transgenic gastroenteritis virus potatoes have been used in human trials at the University of Maryland Vaccine Centre.
Sue Page practises in Lennox Head and is the division's main spokesperson on immunisation issues.
This article was published in GPSpeak in February and April 2001. It was updated in September 2003.
References:
(1) The Australian Immunisation Handbook 7th ed. Pertussis; National Health and Medical Research Council 2000; 3.15:171
(2) Australia's Children, Australian Institute of Health and Welfare
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