Friday, March 1, 2013

Fear, Poor Communications and the Nebulas 'Community Benefit'

With the boys 5th birthday approaching, I have spent a substantial amount of time reflecting on the choices I made and taking the time to review my decisions and revise my positions particularly on vaccinations and other preventative health measures. I have been mulling over the whys and how I came to the decision to delay vaccinating my son.

 The main reason was fear. I was scared that I would allow something to be done to my child, it would cause him irreparable harm, and I would have no one to blame but myself. There was nothing in the 10 years of premedical and medical training that calmed these fears. I knew all the facts and statistics. I knew about incidence rates, relative risk, community immunity but none of these things meant shit if there was even a miniscule chance of it harming my precious baby. There were some things that I was able to justify with some credibility but for the rest I allowed my fear to run roughshod over my intellectual integrity.

The fear was compounded by the seeming inability for the public health community to effectively communicate with me. All public health publication I saw was written to communicate complicated ideas to people without much scientific literacy. Often these publications come off as condescending and seem to have the expectation that people will follow their paternalistic edicts without any discussion or inquiry. On the flip side, when you try to research these things you either go to scientific papers that, even with an advanced science degree, take many hours to read, parse and understand or you stumble upon pseudo or nonscientific sources that reflect and feed your fears.

Fear is a huge motivator. It is one of the things that allowed our species to survive. New channels, politicians, advertisers, religious leaders, parents, and swindlers all use it to their benefit. It is our job, however as ever evolving beings to recognize when our fear is overwhelming our reason and better judgment and do what we can to overcome it. We can only use the information we have to make the best decisions we can. If you try to base your decisions based on everything you don’t know you will forever be paralyzed with indecision.
 Below are my initial thoughts on some vaccines/preventative treatment and reasoned revisions of those opinions.

Vitamin K
·         The Facts
o   In the US, this is given shortly after birth (usually within 6 hours) to prevent Hemorrhagic Disease of the Newborn (HDN) which causes bleeding in the brain.
o   Without the injection the incidence is between 2.5 and 17 per 1000 newborns while when it is given the rate falls to near zero.
o   In the countries where it is not routine the incidence can be as high as 30 per 1000.
o   The risk is higher in newborns who are sick, premature or whose mothers take certain medication which inhibit Vitamin K absorption (anti-seizure meds and anticoagulants) or have certain mal-absorptive diseases.
·         Previous opinion
o   When the boy was born I felt that this was unnecessary because I did not have any of the risk factors and there were was some hints in the literature that it increased the risk of a certain type of leukemia.
·         Reasoned Revision/Current Opinion
o   HDN can be very severe if not caught and treated early. The symptoms can also be fairly insidious initially so it can be missed.
o   The link to childhood cancer has been studied extensively and no one has been able to replicate the findings of increased risk.
o   This single shot gives almost 100% protection and is the best measure to prevent HDN until researchers are able to pinpoint a more precise way to determine which newborns are likely develop this condition
Erythromycin Eye Ointment
·         The Facts
o   Used to prevent ophthalmia neonatorum (ON) which causes blindness in 3% of effected newborns.
o   Caused by chlamydia or gonorrhea infections that is passed to the newborn during vaginal delivery.
o   A woman can have chlamydia or gonorrhea without any symptoms.
o   Risk is increased if you have had multiple sexual partners, are under 25 or live in an area where infection rates are high.
·         Previous Opinion
o   I tested negative for Chlamydia and gonorrhea during pregnancy, was in a mutually monogamous relations and had no other so I declined this intervention.
·         Reasoned Revision/Current Opinion
o   I believed then and still do that there are many criteria that should indicate that you make sure that your child receives this intervention
§  If you have ever tested positive for chlamydia or gonorrhea.
§  If you have never been tested for chlamydia or gonorrhea.
§  If you are not in a mutually monogamous relationship with an uninfected partner.
§  If you live in an area with a high rate of infection with gonorrhea and chlamydia.
§  Or if there is any unknown/uncertainty about the above.
o   The recent emersion of antibiotic resistant gonorrhea may in the near future necessitate the use of the equally effective silver nitrate or povidone iodine drops, which are more effective for treating gonorrhea and equally effective in treating chlamydia (Darling and McDonald, 2010)  but do not have an approve formulation in the US.

Hepatitis B
·         The Facts
o   Since the introduction of the vaccine infection rates have decreased by 75-95%
o   Children who become infected usually have no acute symptoms but can be contagious
o   Children have an increased risk of developing chronic infection resulting in liver damage and cancer.
·         Previous Opinion
o   I decided to decline this vaccine when he was born.
o   I was fully vaccinated and was planning on exclusively breastfeeding and not sending him to daycare so I felt that he was not at risk and would still be protected if he got it at a later time.
o   I delayed this vaccine until he was 2.5 years old and was beginning to spend time with adult and children other than family
·         Reasoned Revision/Current Opinion
o   While my intentions were good it is possible that things may not have worked out as we planned and he may have been put at unnecessary risk.
o   I would have this vaccine given at the first office visit after hospital release and then on the recommended schedule (2nd – 1-2 months old and 3rd – 6-18 months)

Flu Shot
·         The Facts
o   Can present with mild upper respiratory symptoms to severe illness and death depending on the specific virus, when and who gets vaccinated and how well vaccine matches circulating virus
o   Complications (pneumonia, ear and sinus infections, dehydration and worsening of chronic conditions) from the flu are more common if you are older (over 65), young children (especially those who are too young to be vaccinated), pregnant women, and people with other conditions like asthma, diabetes or heart disease.
o   Since 1976 there have been between 3,000 to 49,000 deaths attributed to the flu each year.
o   Spread by doplets from coughs, sneezes or speaking in the air or on surfaces
o   It is possible to spread about 1 day prior to symptoms and for 5-7 days after symptoms appear. Young children and immune compromised people may be infectious for longer.
o   The only absolute contraindication is severe allergy to chicken eggs or had severe reaction to flu vaccine in the past
·         Previous Opinion
o   I was very ambivalent about this vaccine for a long time. I was young and healthy and thought the flu was just uncomfortable and not a big deal.
o   I got it some years when it was free and offered somewhere convenient but other skipped it.
o   I avoiding it for the boy until he was 2.5 years old
·         Reasoned Revision/Current Opinion
o   Getting a flu shot protects more than just me (though this is true for all vaccines), it helps keeps all those people who are too young or too sick to be vaccinated or mount a full immune response healthy.
o   Now I make sure that all members of my immediate family get the flu vaccine as soon and as long as they can.
o   This is doubly important if you have friends or family who cannot receive the vaccine (under 6 months, immune compromised or severely allergic to eggs)
Current Childhood Vaccination Schedule
·         The Facts
o   All vaccines are subject to large randomized controlled trials to determine efficacy and safety. These are powerful enough to detect common adverse events.
o   All vaccines are subject to post-marketing monitoring to detect any rare adverse events.
o   The US has an extensive monitoring of adverse events through the Vaccine Adverse Event Reporting System (VAERS), Vaccine Safety Datalink (VSD) and Clinical Immunization Safety Assessment Network sponsored by the CDC and the Post-licensure Rapid Immunization Safety Monitoring System (PRISM) funded by the FDA to capture even the most uncommon of adverse events caused by vaccines.
o   There is no evidence that the entire current vaccine schedule or any part of it responsible for any serious or long term adverse reactions.
o   Despite the greater number of diseases that are being vaccinated against there are fewer chemicals and antigens in the current
·         Previous Opinion
o   In my effort to assuage my fears I took to the internet to research. Rather than finding well reasoned, scientific information explained in easy to understand but non-condescending language I came across websites written in seemingly scientific language by people claiming expertise that fed my fears.
o   I thought that by exclusively breastfeeding and avoiding daycare and other intuitional settings he would be protected until he was fully vaccinated at some later time.
o   Despite the mountains of evidence to the contrary I was swayed by the emotional and fear laced claims of people like Dr. Mercola, Jenny McCarthy and other of that ilk.
o   I avoided all vaccines until the boy was nearly a year old and then I spaced them out, getting only a single vaccine at a time.
·         Reasoned Revision/Current Opinion
o   With any future children I have every intention of getting all vaccines on the prescribed schedule.
o   The benefits of vaccines go way beyond keeping an individual from contracting an illness.
o   Population wide prevention of vaccine preventable diseases (community immunity) is an important benefit of the current vaccine programs. When uptake of vaccinations diminishes the risk of outbreaks increases.
o   Since the vaccine campaigns have been so successful the current generation has no experience with the ravages of illnesses that they prevent and so tend to place more weight on the possibility of rare side effects than on the more common effects of the illnesses themselves.
o   The vaccines are placed in the vaccination schedule at particular points in time to ensure that children are protected from illnesses when they are most susceptible. Delaying them puts them at risk when they are most vulnerable.

TL:DR: I didn’t vaccinate my son out of fear of the unknown but now I do because of an understanding of what I (we) do know. (We can only do the best with what we know. When we know better we will do better)