by David Isaacs
Similarly, Australian experts moved swiftly to refute the validity of Wakefield’s message in the mainstream media and there was no fall in MMR immunisation rates in Australia. People may be more trusting of their own doctors than of doctors from overseas. A coordinated response by trusted health professionals probably helped undecided parents.
Conflict is integral to human interactions. The mainstream media and social media sometimes talk about immunisation as if opinions are dangerously polarised. If you search the internet for information on the topic, you could be forgiven for thinking opinion is almost equally divided for and against. Is this true? Is polarisation a real problem, or is it exaggerated?
In surveys asking the public which professionals they trust most, nurses usually come top of the list, followed by doctors. Politicians come bottom.
It’s just as well that the United States public listens to doctors and nurses rather than politicians on vaccine safety. Donald Trump is notoriously convinced that vaccines cause autism and his willingness to share this belief predates his presidency. His attempts to convey his anti-vaccine message are characteristically inarticulate. In 2014, before he was president, Trump tweeted: ‘Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesn’t feel good and changes – AUTISM. Many such cases!’ In 2017, in a conversation with educators, the president said to a teacher in the audience: ‘So what’s going on with autism? When you look at the tremendous increase, it’s really – it’s such an incredible – it’s really a horrible thing to watch, the tremendous amount of increase.’ Trump met Andrew Wakefield in 2016 and the next year Wakefield attended the president’s inaugural ball.
Trump’s aversion to scientific evidence is illustrated by a 2017 directive to the CDC not to use the terms ‘evidence-based’ or ‘science-based’ in reports. Fortunately, the evidence suggests relatively few people in the United States pay attention to Trump’s diatribes on vaccines and autism. ‘Trust me, I’m a politician’ does not seem to have caught on yet, at least as far as vaccine safety is concerned.
Trump’s 2014 tweet draws a facile link between the increase in the number of vaccines and the increase in autism. The most likely reason autism has increased so obviously is that we have changed the way we define it.
Leo Kanner, an Austrian-American psychiatrist, wrote the seminal paper first describing autism in 1943. It was called ‘Autistic Disturbances of Affective Contact’ and described 11 children who were highly intelligent, but displayed ‘a powerful desire for aloneness’ and ‘an obsessive insistence on persistent sameness’. Some of them had ‘islands of brilliance’, being extraordinarily talented artists or musicians, but they were all very poor communicators, and some were totally mute. With time, the definition of autism expanded to include children who were developmentally delayed.
Recently autism has been reclassified as ‘autism spectrum disorder’. As the name suggests, it is now a spectrum that includes children and adults who have difficulties with communication and social interaction, and display restricted or repetitive behaviours and interests. This is a very far cry from Kanner’s original narrow definition. In fact, a definition that vague makes me wonder if many of my quirky colleagues don’t fulfil those criteria! Probably I do too. As I once wrote, only half in jest, if it’s a spectrum, aren’t we all on it?
In 2014, the CDC reported a study showing that 1 in 68 United States children (1 in 42 boys and 1 in 189 girls) had been diagnosed with autism spectrum disorder. That means there is one boy with autism in every large United States class.
One extremely unattractive aspect of the recent immunisation controversy has been the fierceness of a very small but vociferous group. In Autism’s False Prophets, Paul Offit sets out the scientific evidence suggesting MMR vaccine does not cause autism. He has received hate mail and death threats because of his stance. Paul Offit is a courageous man. He does not deserve to be told ‘Your day of reckoning is coming’ or the even more sinister ‘I know where your children go to school.’
It is not clear why autism stimulates such vitriol. If it comes from parents of autistic children, we can at least understand their pain and frustration. If not, there is little excuse.
Why is there scepticism?
Opposition to vaccines is not confined to the autism controversy. In 2008, Jenny McCarthy and Jim Carrey held a rally in Washington DC called ‘Green Our Vaccines’ to raise awareness of ‘toxins’ in vaccines. They were photographed wearing green T-shirts bearing that logo. They argued that substances like thiomersal – which we heard about in the previous chapter – cause autism and should be removed from all vaccines. The trouble is that without preservatives, vaccines are more likely to be contaminated and cause infections.
In 2005 Jenny McCarthy founded Generation Rescue, a ‘non-profit’ organisation that advocates that autism and related disorders are primarily caused by environmental factors, particularly vaccines. Jenny McCarthy certainly seems to have profited from her opposition to vaccines, having published nine books in which she promotes her beliefs.
Considering that medical experts rate immunisation as one of the most important medical advances ever, it is intriguing that there is, and has always been, so much opposition. Part of the reason is rooted in history. When smallpox vaccination was introduced in England in the early 19th century, it was the first major immunisation program in the world. It was a novel idea and public resistance was perhaps unsurprising. As late as 1906, in the preface to his play The Doctor’s Dilemma, George Bernard Shaw – no lover of the medical profession – called smallpox vaccination ‘a particularly filthy piece of witchcraft’.
Nowadays there are anti-vaccination movements in many Western countries, but the extraordinary success of immunisation programs means they lack the widespread appeal of the original anti-vaccination leagues.
Vaccine sceptics and opponents say today – as George Bernard Shaw once did – that putting foreign proteins into our bodies is dangerous and unnatural. They are correct on both counts, but the extent to which they are correct requires major qualification.
Firstly, all medicines are potentially harmful and vaccines are no exception. In the last chapter we looked at several occasions in history when vaccines have caused tragic fatalities. While vaccines are getting safer all the time, we should never be blasé about the risks.
Secondly, although the human immune system evolved to cope with foreign micro-organisms and foreign proteins, vaccines include modifications of those organisms that render them immunologically distinct. However, medicine and surgery mainly involve using techniques that could be called ‘unnatural’. We use the natural hormone insulin to treat diabetes mellitus, but we modify the insulin (make it ‘unnatural’) to alter its strength and prolong its effects. If a baby gets stuck during delivery we would perform an ‘unnatural’ Caesarean section to save the life of both mother and baby. It seems that what is natural and what is unnatural are not very useful concepts in determining what is best for human health.
Julie Leask is an internationally acclaimed social scientist and an associate professor of nursing at the University of Sydney. Professor Leask describes how anti-vaccine parent groups may express antipathy to medical intervention and prefer natural or alternative therapies, such as homeopathy, chiropractic, reflexology and traditional Chinese medicine. They may maintain that a healthy diet is all that is needed to protect their children against infectious diseases. They promote themselves as champions of transparency in public information and of individual choice. They perceive that vaccine companies not only make huge profits from selling vaccines but also exert a pernicious influence on healthcare professionals, research institutes and governments, which for them comprise a ‘system’ that drives the expansion of immunisation programs.
In general, parents who refuse all vaccines are very unlikely to change their minds. If my colleagues and I look after an unimmunised child in hospital who is critically ill from an infection that would almost
certainly have been prevented by routine immunisation, the parents never admit to feeling guilty and almost never agree to let us immunise the child to prevent other infections.
Pru Hobson-West, an English social scientist, describes how a major strategy of vaccine-critical groups is to reframe risk. Doctors preach the need to weigh up the benefits and risks of any medical intervention, including immunisation. The risk of getting life-threatening acute encephalitis from measles is one in a thousand; the risk of getting encephalitis from MMR vaccine is one in a million. To a doctor those figures clearly favour measles immunisation. But a vaccine-critical group will argue that all of us are individuals, which means to them the true risk to each child from vaccines is unpredictable. This emphasis on uncertainty breeds uncertainty. I was recently unable to persuade a father that his child, who had been born without a spleen and was thus at high risk of infection, should be immunised. Although I told him the risk of a life-threatening infection was one in eight and the risk from the vaccine less than 1 in 10,000, he declined to immunise his child, saying he was too worried about vaccine side effects.
Many people, not just committed anti-vaccinationists, fear that giving lots of vaccines might weaken the immune system. They need not worry. The human immune system has evolved to cope with an almost infinite variety of new threats. Indeed, Australian virologist and immunologist Sir Macfarlane Burnet is famous for demonstrating the range and remarkable flexibility of the human immune system.
The most recent evidence suggests that not only do lots of vaccines not weaken the immune system, but for some vaccines the complete opposite is true. Professor Julian Higgins and colleagues in Bristol looked at 34 large-scale studies of vaccine impacts and reported their results in the prestigious British Medical Journal in 2016. Vaccines against measles and tuberculosis stop children dying from those diseases, but they also stop children from dying from other causes over the following two to five years. A child in a developing country who is given a measles-containing vaccine such as MMR vaccine is 25% to 50% less likely to die from any cause than a child who does not get measles vaccine. A child in a developing country who is given BCG (anti-tuberculosis) vaccine is 30% less likely to die from any cause than a child not given BCG vaccine. We do not know the precise scientific basis for this, but there is little doubt that it is due to stimulation of the child’s immune system and of their ability to fight off infections. Of course, it may not be possible to replicate these impressive results in Western countries, where childhood mortality is lower, but they illustrate the point that some vaccines strengthen the immune system and not one has been shown to weaken the immune system.
HPV vaccine scare campaigns
The new human papillomavirus (HPV) vaccine protects against a virus that can cause cervical cancer. HPV vaccine has been the subject of many scare campaigns.
Clinical trials of HPV vaccines in Europe, North America, South America, Asia and Australia published from 2006 onwards found the vaccine was safe and stimulated an immune response, and the vaccine was introduced in Australia in 2007, as we heard in Chapter 7.
In Japan, there was initial enthusiasm, and the uptake of government-funded vaccine by schoolgirls was about 70% in 2013, as it was in Australia. However, media reports of a preliminary (and allegedly fraudulent) mouse study showing the vaccine caused brain damage and unconfirmed video reports of girls in wheelchairs or having convulsions supposedly after receiving the HPV vaccine fuelled anti-vaccine sentiment. Anti-immunisation groups blamed the vaccine for causing chronic body pain and heart and neurological troubles.
Despite a total absence of good evidence of harm, the Japanese Health Ministry hastily suspended the vaccination program pending an investigation. In early 2014, the ministry’s panel concluded that there was no evidence the vaccine caused the reported adverse events. However, HPV immunisation rates plummeted from 70% to less than 1% within a year, and the health ministry has never restored its recommendation to give HPV vaccine, even though the vaccine is still government-funded.
Studies worldwide have found that girls report such symptoms just as commonly when unvaccinated as after vaccination with HPV vaccine, and that the vaccine almost never causes serious adverse side effects. European and North American expert reviews agreed the vaccine did not cause the symptoms. The WHO condemned the Japanese Government’s risk-averse suspension of their recommendation of HPV vaccine. The WHO’s Global Advisory Committee on Vaccine Safety stated pointedly: ‘Policy decisions based on weak evidence, leading to lack of use of safe and effective vaccines, can result in real harm.’
Although immunisation levels remain high in Australia, in Denmark and Ireland immunisation levels have fallen, and the adverse publicity from Japan and elsewhere has certainly not helped countries like France, where fewer than 15% of adolescent girls have received the recommended three doses of HPV vaccine. Maybe, as with smallpox vaccine, the eventual success of HPV vaccine will win round the doubters, but it is a tragedy that many young women who will develop cervical cancer could have avoided it through HPV immunisation.
One reason for opposition to HPV vaccine, I believe, is that it relates to an infection that is not classified as a sexually transmitted disease but is nevertheless transmitted through sexual intercourse. United States opposition to HPV vaccine stemming largely from the religious right focused on a strange conviction that girls given the vaccine would be more likely to have sex. One United States mother was quoted as saying, ‘I realise it’s probably more about my squeamishness with the thought of her becoming sexually active than the vaccination itself. It’s not the science. I think it’s my own issues around her developing sexually.’ Scientific studies show that girls given HPV vaccine are no more likely than girls not given the vaccine to become sexually active, but it is clear that many parents’ fear of HPV vaccine really represents their fears around their children’s sexual maturity.
British independent broadcaster Joan Shenton, who is also an AIDS denier (someone who does not accept that the HIV virus causes AIDS), made a short anti-HPV vaccine film called Sacrificial Virgins. Shenton planned to come to Australia in August 2018 for panel discussions accompanying showings of her film, but had to cancel when the Australian Government did not grant her a visa in time, raising controversy about the balance between freedom of speech and public health. (When our immunisation research workers decided to check out the content, they accidentally found themselves watching an X-rated Nigerian Nollywood film called The King’s Sacrificial Virgins. The blood-curdling screams of the virgins being sacrificed in gory technicolour echoed around the immunisation department, causing amusement and embarrassment in equal measure.)
After a school-based program was introduced in Australia in 2007, the National HPV Vaccination Program Register recorded that 74% of girls received a full course; the number reached 78% in 2015. After the vaccine was extended to Australian boys, 62% of eligible boys received a full course in 2014 and 70% in 2015. The uptake rate in Australian girls is as high as, and in Australian boys is higher than, anywhere else in the world. In contrast, data from the CDC show that only 18% of eligible teenage girls received a full course when State programs were introduced in the United States in 2008. The numbers rose gradually to 43% for girls and 31.5% for boys in 2016.
Two additional reasons have been put forward for the low uptake of HPV vaccine in the United States compared with Australia. The first involves mainstream and social media.
Katie Couric is an award-winning journalist and author who has worked as a news presenter for three United States television networks. From 2012 to 2014, Couric hosted her own daytime talk show, Katie. On 4 December 2013, she hosted an episode entitled ‘The HPV Vaccine Controversy’. A promo for the show said: ‘The HPV vaccine is considered a life-saving cancer preventer . . . but is it a potentially deadly dose for girls? Meet a mom who claims her daughter died after getting the HPV vaccine, and hear all sides of the controversy.’
After the show, Couric was criticised
by doctors for airing the anecdotes of people who described adverse events and a death that were probably coincidental and highly unlikely to have been caused by the vaccine. Scientists pointed out that these sorts of stories elicit a strong emotional response in audiences but are a poor way of equipping them to weigh up the risks and benefits of a new vaccine.
A week later Couric apologised – not on air, but in the Huffington Post – for giving too much emphasis to adverse events, and pointed out that she had had her own two daughters immunised with HPV vaccine. She wrote:
The federal government has a system for reporting adverse reactions following immunization with any vaccine. For the 23 million doses of Gardasil [HPV vaccine] distributed in the United States from 2006 to 2008, 12,424 adverse reactions were reported, a rate of 5.4 per 10,000 doses, and the vast majority of these were minor (transient fever, rash or sore arm). Furthermore, only 772 of the 12,424 adverse reactions were reported to be serious (persisting symptoms such as sore joints, or very rarely a severe allergic reaction called anaphylaxis), a rate of 0.3 per 10,000 doses. These rates are low compared with other vaccines.
Two weeks after the HPV vaccine show aired, the syndicate announced that Katie had been cancelled. They did not say whether it was due to low ratings or the controversy over the vaccine.
It is easy to criticise the mainstream media for poor coverage of immunisation issues (as I have already done in this book). One time a journalist interviewed me over the telephone then asked me for the name of an anti-immunisation advocate. I asked her: if I had been describing the harms of alcohol abuse, would she have asked me for the name of an alcoholic to present the other side of the ‘debate’?