For the past few weeks, I’ve been immersed in the measles conversation, reading about debates on the news, and volatile arguments on social media. The biggest issue I have is that the only positions/arguments that seem to get attention are either purely anti-vaccine or purely pro-vaccine. The unfortunate result is that those parents who are seeking objective information from the Internet are undoubtedly at a loss.

30083240_mlAs a physician, my conversations with colleagues and parents over the past 15 years has given me a perspective on the vaccine debate that just isn’t well represented on the internet. It’s either “Jail anti-vax parents” as expressed by USA Today, or “none of the vaccines are safe.” The problem is that very few voices are attempting to talk about it objectively. The result? Those physicians who are the loudest, most passionate, or use the strongest language such as “absolutely yes” or “absolutely no” get the spotlight because parents want that definitive answer, and it’s exciting for the media to publish extreme positions.

Let me say first that I believe vaccines are generally safe, effective, and beneficial to our society. This opinion is obviously not shared by everyone in medicine, regardless of whether they are a naturopathic, integrative, or conventional physician. There are MD’s and DO’s who are staunchly anti-vaccine, and there ND’s who are pro-vaccine. It is important to state here the significant example of the vaccine position paper by the Scientific Affairs Committee of the American Association of Naturopathic Physicians. The SAC consists of our profession’s most knowledgeable, highly regarded PhD researchers and physicians. The SAC supports the vaccination schedule.

As for the debates, there are points from each side that need clarification. Those who are most polarized on either side will mention some of these points without the others, so it’s important to talk about them all.

First, let’s talk about the number of cases, which many are claiming is insignificant. Some contest that this shouldn’t be considered an “outbreak”, but let’s look at the World Health Organization’s definition of the term:
“A disease outbreak is the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season…A single case of a communicable disease long absent from a population, or caused by an agent (e.g. bacterium or virus) not previously recognized in that community or area, or the emergence of a previously unknown disease, may also constitute an outbreak and should be reported and investigated.”

Considering that the U.S. was measles-free in 2000, the increased numbers of cases would fit into the outbreak definition. In Arizona, we have 7 reported cases as of January 29, 2015. It has a 21-day incubation period, so in about a month we will know if it’s spreading in this state. Most cases have the following symptoms: fever, cough, red eyes, runny nose, and a rash. In the worst-case scenario, a patient could develop encephalitis, or swelling of the brain. This is, factually, devastating for anyone. It can have life long effects including brain damage, deafness, and/or other neurological impairment. Chances of this are approximately 1 out of 1,000. If the infected person does not get encephalitis, it can still occur years later, a condition called subacute sclerosing panencephalitis (SSPE). SSPE however, is rare and the risk is about 7 out of 1,000,000. Patients at highest risk for death from complications of measles are those who get pneumonia, which occurs in approximately 5% of the infected. Some refer to these facts as “scare tactics”. The truth is, the numbers are what they are. If these numbers scare you, so be it. It doesn’t change the fact that, although rare, they can happen. It all depends on what is more concerning to you: the potential infection and its possible effects, or the possible effects of the vaccine.

On that note, let’s move on to the possible effects of the vaccine. Does it cause autism? This is a debate that will never end. There is a large body of research now that shows that it is not necessarily related to the development of autism. However, it is easy to find criticism of this data on the internet, and those criticisms can be understood often only by someone who is an expert in research design and statistics. There are also criticisms of those criticisms. The problem with looking at the research with intentions of getting an answer to the question of “Does the MMR vaccine cause autism” is that there are many factors involved with autism. Environmental toxins, both pre- and post-natal, surely have an effect, as well as prenatal factors of low vitamin D levels in the mother or untreated maternal fever during pregnancy. About 60% of my patients have a diagnosis of autism. Some of those children received the MMR, some have not, and some have not received any vaccines at all by the parents’ choice. Autism can occur without being vaccinated.

Some autistic children do seem to have a stronger response to vaccines. There’s some interesting data showing a stronger immune response to the measles vaccine in autistic children by Singh in the journal Pediatric Neurology in 2003, entitled “Elevated levels of measles antibodies in children with autism.” Additionally, patients with a mitochondrial disorder may have severe reactions to vaccines, as evidenced by the case of Hannah Poling. For those readers who are not medically privy to what the mitochondria are, think back to those cell models you made in junior high using the kidney beans for the cell’s energy producers…yes, those are mitochondria. The downside is that in order to get a definitive diagnosis of this disorder, a muscle biopsy is necessary. Hardly a routine option for parents who want to know if their child has the disorder! There are however blood tests that can be ordered like lactic acid, ammonia, and carnitine that may give clues to a child’s mitochondrial function.

22277515_mlThe opinion, “Vaccines don’t work anyway, so why do them” is likely fueled by the U.S. pertussis outbreaks in vaccinated populations from the past few years; The majority of Arizona’s cases from 2003-2005 were in communities with high immunization rates. In California’s 2010 pertussis outbreak, only 9% of the 4,415 cases were in unvaccinated people. I believe this is the result of trying to find an equilibrium between a vaccine’s side effects and its effectiveness. Prior to 1996, DTP (diphtheria, tetanus, pertussis) was the only vaccine used. It had a high enough rate of adverse effects to influence the development of a “nicer” vaccine, DTaP (“a” for acellular), which had less of these effects. Here’s the catch: by making a nicer vaccine, we see its effectiveness clearly decline since the CDC recommended the DTaP over the DTP in 1998; Pertussis cases increased from approximately 6,000-8,000 cases per year to 11,000-48,000 cases per year by 2014. That’s a huge jump.

Here’s the link if you’re interested: http://www.cdc.gov/pertussis/surv-reporting/cases-by-year.html
So, we are all caught in a tough spot. And I say “all” because no one, in their right mind, on either side of this debate wants kids to have pertussis nor do we want a vaccine that causes side effects. In the case of the pertussis vaccine, nicer vaccine = less effective, more effective = more side effects. We clearly still haven’t found the perfect balance, but it doesn’t mean we should throw the vaccine out with the bath water.

Some vaccines don’t work on some people, meaning that a patient may still get the disease they have been vaccinated for, or they don’t produce a protective antibody level after vaccination. Research shows us that those with Type 1 diabetes, a predisposition to autoimmune disease, or celiac patients who are not avoiding wheat may produce less of an antibody level when vaccinated. And, there are patients who don’t have any of these conditions and still don’t produce protective levels of antibodies after vaccination. This fact has been used in the argument: “Well, they don’t work anyway, so why do them?” Well, if you need 100% effectiveness to believe something works, show me ANYTHING in medicine, naturopathic or conventional that works 100% of the time. Nothing like that exists. The MMR shows greater than 90% effectiveness, which is a spectacular success rate, but the more a virus spreads, the more opportunities it has to find people in which the vaccine didn’t hold. The data collected so far from the CDC as of January 21, 2015 says:

“Vaccination status is documented for 34 of the 59 cases. Of these 34, 28 were unvaccinated, one had received one dose and five had received two or more doses of MMR vaccine.”

In this disease outbreak, most of the reported cases were in unvaccinated people. The same goes for the U.S. measles cases in 2011. The CDC reported that 86% of the patients who contracted measles in 2011 were unvaccinated. Therefore, if you are arguing against the effectiveness of vaccines, you can’t use information from an outbreak from one bug and apply that to all the vaccines.

An opinion that has been circulating for years is that getting any of the infections that the vaccines are made to prevent is better than getting the vaccine itself. This is a loaded belief, especially when we break it down to the specific diseases. Which disease are we referring to? Pneumococcal meningitis that kills 30% of those that contract it regardless of hospital interventions? Haemophilus influenzae type B meningitis that does the same? I disagree that the disease is “better” than the vaccine in most cases. This opinion likely developed for several reasons, one of which is the long-term protection of the actual infection compared to the vaccine. For example, let’s look at chicken pox. Generally, getting the chicken pox infection has stronger long-term protection from getting it again when compared to the vaccine’s preventative abilities. So, those opposed to vaccination use this as a point for their argument against all vaccines. But, people do get chicken pox more than once. It happens. So which is better to have? Some feel it depends on the disease’s potential to kill someone, and the chicken pox death risk was around 25 out of 1,000,000 before vaccination was available. Another point that circulates is that those who get the diseases enjoy a healthier future after the infection. This may have come about from research published in 2002 by von Mutius in the Journal of Allergy and Clinical Immunology, showing that previous measles infection may decrease the risk of asthma later in life. However, the author states that this effect is not very strong:

“When we analyzed measles infections separately we found that a diagnosis of asthma was less common in children who had had measles than in those who had not, but the small number of measles cases meant the difference was not significant.”

Other research says quite the opposite, for example, from the Journal of the American Medical Association:
“Based on our data, measles and atopy (allergy) occur more frequently together than expected, which does not support the hypothesis that experiencing natural measles infection offers protection against atopic disease.” (Paunio, JAMA, January 2000)

… and a Polish Journal stating similar findings:
“The results of the study showed that susceptibility to upper respiratory infections was about twice as high among those children who experienced measles.” (Jedrychowski W, Przegl Epidemiol. 2003)

Parents often ask the question, “Are there any treatments for measles that currently exist that don’t involve medication?” Yes, possibly. Again, nothing is 100% effective, but let’s looks at some interesting research on vitamin A by Coutsoudis. Vitamin A supplementation in African measles patients significantly decreased diarrhea, herpes incidence, and respiratory-tract infections, and increased weight gain compared to placebo. 90% of the patients in this study with severe measles had low vitamin A levels (American Journal of Clinical Nutrition, 1991). Coutsoudis also found that Vitamin A supplementation in African children resulted in an increase in total white blood cell number and measles antibody concentrations (The Pediatric Infectious Disease Journal, 1992). This begs the question, “which came first, the low vitamin A levels or the measles?” The answer is not entirely clear from these cases, but consider this: worldwide, measles deaths approach 150,000 per year. To be exact, there were 145, 700 measles deaths in 2013 globally, which amounts to about 16 deaths every hour. The reference to how measles deaths decreased dramatically before the measles vaccine was invented may be somewhat true, but this doesn’t mean the vaccine is useless. 145,700 deaths is a lot of deaths, especially when they can be prevented. We certainly don’t see this kind of mortality from measles in developed countries, so it’s likely a combination of malnutrition and/or a lack of vaccine access. Nevertheless, U.S. measles cases are also characterized by low vitamin A status:

“We studied 20 children with measles in Long Beach, California, and found that 50% were vitamin A deficient. This frequency among presumably well nourished American children supports evaluation of vitamin A status as a part of acute management of measles in the United States.” (Arrieta, Journal of Pediatrics, 1992).

So even here we either have children who will get measles because they are deficient in vitamin A, or the infection uses up our preexisting vitamin A storage. Regardless, all this research speaks to the benefits of vitamin A. Whether it prevents measles is not entirely clear, but it certainly can help as a treatment.

The bottom line is that we all want the same thing. I truly believe deep down inside that those on both sides of the vaccine controversy want our children to be healthy and happy. Therefore it is imperative to keep the passion in our debates focused not on clenching to our position, but to ask every question possible.