An Apple A Day

Immunizations have been all over the news lately, even entering the political debates.  A couple of the discoveries have confirmed clinical impressions, including some I shared with you before.

As I mentioned in an earlier newsletter, the current whooping cough (pertusis) epidemic has been remarkable to me because, while I have had patients with whooping cough almost every year for the last 25 years, I have not had a single patient with whopping cough during what is supposedly a revolutionary epidemic.  Why is that?

Data now show that at least 80% of the children developing whooping cough in the current epidemic have been immunized as officially recommended.  A brand new study of this outbreak, conducted in Marin, found that immunity is lasting only 3 years after completing the full 5 shot DTaP immunization series.  Older, previously vaccinated children are now the most vulnerable to the disease.  One public health response has been a call to vaccinate an even higher percentage of the population, because those who are not vaccinated must be spreading the disease, overwhelming the vaccination.

I would think that the correct conclusion would instead be to reconsider the relationship between the vaccine and the disease. Maybe the disease is evolving to outrun the vaccine?  Might there even be MORE vulnerability to whooping cough among those immunized, at least after a few years, than the rest of us? Clearly the vaccine, even five shots worth, is not doing the job.

I have never been a fan of the chicken pox vaccine, and research data makes me feel like even harsher criticism is deserved.  Research now indicates that immunity from the vaccine disappears after only 5 -7 years.  That is a triple “ouch”, the first for the shot, the second because the shot did not protect for very long, and you can read the third in the next paragraph.

Adding to the uncertainty, there are data indicating that lowering the rate of chicken pox has increased the rate of shingles suffered by adults.  Projections are that as high as many as 50% of adults will develop shingles because their immune systems will not be not “reminded” about the virus, due to lack of virus exposures in daily life. Formerly the incidence was believed to be under 5%.

Of course, most of us would choose to risk our health in favor of our children’s health.  However the small to moderate risk of serious problems with each could make this rationale debatable.  Chicken pox is usually a mild illness, and many times parents of children who have gotten chicken pox have expressed their surprise to me, as what they had read of the disease had made them quite afraid.  That said, as many as 5,000 children a year were hospitalized in the USA with complications before the vaccine became available.  Then again, in the same time period, we averaged 100,000 pediatric hospitalizations annually for diarrhea.  Postherpetic neuralgia, a complication which occurs in about 13% of shingles cases, typically causes pain for months and sometimes years.  Unfortunately, at this point I think there is more justification for shingles vaccine in our aging population as a consequence of vaccinating children.

It seems to me that, even without questioning immunizations for other reasons, there is rising cause for skepticism and critical reappraisal.  The bottom line is that these immunizations are, at best. not as advertised. They are not working very well and it is unwarranted to simply blame those who choose to limit vaccinations for failure of the vaccinations.  Many physicians were surprised by a recent study which found that almost 3/4 of parents had concerns about immunizations.  I am surprised also, but by the minority who did not have questions.

As of July 1, children in California are subject to a new law which requires an additional dose of the whooping cough (pertusis) vaccine. Unlike the “required” doses for younger children, which can be waived after a discussion between the child’s physician and parents, this draconian legislation only allows a waiver if the parents sit down with a school representative. The hope being that this additional pressure will reduce the number of families refusing the vaccine. Beyond the bizarre message that it is better to discuss a medical issue with a school secretary than a physician, I have some other thoughts to share.

The impetus for this new law is an epidemic described as the worst in decades. If you are at all open to vaccinations, reports of an epidemic of a disease which often makes small children very ill, will certainly grab your attention.

My own experiences are far less compelling, in fact I am really dubious about this situation. Given the nature of my practice, I have far more experience with whooping cough than the average MD.

During my training, many of my patients were Hmong refugees from Southeast Asia. I saw much more extreme illness among these patients as they had had limited access to western health care but more because they were extremely independent and did not do what we told them to do unless they agreed it was a good idea. We would present nightmarish, worst-case scenarios to them hoping to convince/coerce them and earn their compliance with our instructions. These situations were not minor by any means, a young man with a brain abscess and a laboring woman with a prolapsed umbilical cord immediately come to mind. Although we were sincere and well-intentioned, it was disturbing and quite enlightening to see how often we were wrong.

I have learned to honor, respect and prefer patients who care enough about their health to make their own decisions. Often patients have their own personal wisdom, extending beyond the inevitably limited and generic scientific data. I like as much information as possible. When a course of treatment is not 100% clear, it seems to me that, even more than usual, the patient has an important decision-making role and should provide input. I am not the boss, I work for my patients.

Consequently, for decades the majority of my patients have not toed the party line as far as immunizations. Actually, that is not unusual. At an AMerican Academy of Pediatrics meeting I attending many years ago, the speaker asked the audience to raise our hands if we gave a specific vaccination to our patients. The minority of the medical doctors at this meeting gave their patients vaccinations “by the book”. I think the physician “compliance” rate would be higher now, but in any event, my patients are far less likely to be fully immunized.

As could be expected then, I have treated many patients for whooping cough. 20 years ago I personally learned what it was like after my two oldest children (who were then quite young) and I caught whooping cough from a friend’s child after having dinner at their home in the Bay Area.

Here is where it gets weird. Every year I have had patients with whooping cough, UNTIL this “epidemic” began. Yep, I have not had a single patient with whooping cough during this “epidemic” despite the fact that I had them every year before the “epidemic”. Expecting to see it, I even referred a couple of possible cases to public health for testing. Neither of them had whooping cough. Adding to the mystery – Off the record, a public health official told me that every case of whooping cough she had seen had been properly immunized.

The old whooping cough vaccine (DPT vs today’s DTaP) was ineffective and toxic. A study by the Minnesota Department of Public Health found that children who received the original HIB vaccine were MORE likely to get the disease than those who did not. (The HIB vaccine used for the last 15 years seems to work much better). There is precedence for vaccine-failure. Maybe I am just a statistical aberration this time? Something odd is going on.

Shingles Vaccine
There has also be a media blast promoting the shingles vaccine. Shingles is a reappearance of the virus that causes chicken pox. That class of viruses (including genital herpes) lives in the nerves even when otherwise invisible and inactive. It lies dormant for decades. Shingles is the reemergence of the virus. It appears that weakening of our immune system with age and stresses allows the virus to break loose. Shingles can be very disabling mostly because of the chronic nerve pain it can create (postherpetic neuralgia). No treatments – conventional or alternative are as reliable as we’d like.

Data suggest that the vaccine is highly effective, with minimal adverse effects and that shingles is quite common. Looking at it that way, the recommendations for most people age 60+ to get the vaccine seems reasonable. I am just a bit uncomfortable with this. Over and over and over we find that treatments turn out to be both less effective and more harmful than we thought after large number of people start using them. The data cited in these studies indicate that a much larger percentage of people get shingles than I see in my practice. Does that mean that the habits of my patients make them less likely to develop shingles or that these data are suspect? I do not know and that uncertainty will continue for a while inevitably and annoyingly.

Swine Flu
BTW – Remember all the terror about the swine flu? Currently the swine flu is under discussion in many medical journals although not because of the health impact. The most highly regarded medical journals are pointing out that it was not significantly worse than an average annual flu and then asking why there was such hysteria. I suggest that the editors reread their own publications and accept responsibility for their own lack of skepticism.