Monday, October 3, 2011

The Good, The Bad, The Ugly (Marin IJ)

You may have noticed that vaccines are back in the news. In fact, the last few weeks have brought several related stories, which as a vaccine advocate, I would categorize as the Good, the Bad and the Ugly (yes, vaccines and Clint Eastwood movies do have something in common!) These developments can be summarized as 1) Good; rotavirus vaccine benefits children and public health, 2) Bad; pertussis (whooping cough) vaccine wears off sooner than previously thought (after about three years) and 3) Ugly; the Human papillomavirus (HPV) vaccine was blindsided by hearsay from a U.S. presidential candidate. More plot details below…
Good: Rotavirus vaccine decreases health costs
Have you heard of rotavirus? As a medical student studying for the boards, I had trouble remembering what type of infection this bug caused until I learned the mnemonic R-O-T-A, which stands for “right out the a@*&#.” That pretty much sums it up. Rotavirus is a leading cause of diarrhea, especially in children under the age of five. Tens of thousands of kids visit emergency departments each year because of rotavirus (which can cause life-threatening dehydration), and thousands more will require hospitalization for re-hydration. According to the CDC, just five years ago, rotavirus was responsible (annually) for approximately 55,000 to 70,000 hospitalizations and 20 to 60 deaths among young children. Even in mild cases, rotavirus is a bummer for everyone involved, except, that is, for the diaper industry.
The good news is that there are now two licensed vaccines against rotavirus (RotaTeq and Rotarix) and recent evidence suggests that they are working well. In the September 22nd issue of the New England Journal of Medicine (NEJM), researchers from the CDC reported the results of a 2001-2009 study comparing pre- and post-vaccination outcomes. Their results suggest that the vaccine (first widely available in 2007) resulted in an approximately one-half reduction in diarrhea-related ED visits and hospitalizations. Furthermore, the researchers calculated that the vaccine had likely prevented over 20,000 hospitalizations a year since 2007, resulting in a health care cost savings of over $90 million a year. I think you’ll agree; that’s a public health benefit we shouldn’t be flushing away.
Bad (well, not totally bad): Pertussis vaccine wears off earlier than thought
Hopefully by now everyone knows that we are in the midst of a pertussis (whooping cough) epidemic – one in which (quite regrettably) Marin County has led the way. This epidemic is multi-factorial – it is due in part to natural disease fluctuation, but also related to significant rates of personal belief exemptions (PBEs) for vaccines and waning immunity in older kids and adults. We have suspected for some time that the typical schedule of acellular pertussis vaccination (in older kids and adults) does not provide adequate protection and very recent (and still unpublished) evidence from the 2010 pertussis outbreak seems to confirm this. Dr. David Witt (infectious disease) and Dr. Paul Katz (pediatrics) from San Rafael Kaiser Permanente recently studied over 15,000 kids under the age of 18 in Marin County and identified 132 confirmed cases of pertussis. Their preliminary results, presented two weeks ago at the American Society for Microbiology in Chicago, suggest several important trends; 1) vaccinated children (age 2-18) are less likely to get whooping cough than unvaccinated ones, 2) younger children (age 2-7) who are vaccinated are well protected against disease and 3) older kids (with a peak around age 12), even if vaccinated, are very susceptible. In fact, the risk for 12-year olds is approximately ten times higher than for 2-7 year olds. This, then, seems to be good justification for the idea of a pertussis booster shot (as now required by state law AB 354) for 7th-12th graders. Fortunately, and this is where the bad news is not really so bad, Marin County seems to be doing very well with these boosters. According to public health officer, Dr. Jason Eberhart-Phillips, “We are nearly there to full compliance in Marin at this time. Local education officials understand and value the health and well-being of their students! “

Ugly: The HPV vaccine flap
Genital warts are not a pleasant topic. Especially when you consider that the causative virus (HPV) is a major risk factor for cervical cancer. Cervical cancer is nasty, even for cancer, and it kills young women. If you have any doubt about how horrible this cancer can be, consider this description of metastatic disease from The Immortal life of Henrietta Lacks by Rebecca Skloot… “Henrietta’s body was almost entirely taken over by tumors. They’d grown on her diaphragm, her bladder and her lungs. They’d blocked her intestines and made her belly swell like it was six months pregnant.” Fortunately, HPV immunization offers significant protection (70% or so) against cervical cancer in addition to genital warts. But despite its well-documented safety (over 35 million doses given worldwide), the context of the topic (teenagers having sex) has fueled some political pushback.

On September 13, the day after a GOP presidential candidates debate, Michelle Bachmann claimed on several media outlets that the HPV vaccine was hazardous and could cause “mental retardation.” Later, Bachman told Matt Lauer on the “Today” show that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk." As it turns out, these statements were based, not on fact, but on a single anecdotal account from a woman who had talked to Bachmann at a campaign event. This sort of   “a person I knew had a…” approach to public health is not healthy. In fact, this tact by a public figure was so egregious that Dr. Arthur Caplan of the University of Pennsylvania Center for Bioethics, challenged Bachmann – offering her $10,000 of his own money (to be given to a charity of her choice) if she could, in Caplan’s words, “produce a person within a week who had been made ‘retarded’ by the HPV vaccine, and if that claim could be verified by three doctors.” It’s been several weeks now and Caplan’s challenge remains unanswered. I asked Dr. Caplan to summarize his opinion of the situation:

He says, “Bachmann decided to base her campaign on an anti-vaccination platform. To do so she had to claim that vaccines like the HPV vaccine to prevent cervical cancer are dangerous.  Her willingness to throw away women's lives for political gain is not only unworthy of a Presidential candidate it is morally despicable.”
“As a recent study in NEJM on vaccines against rotavirus demonstrated,” Caplan continues, “vaccines remain our best response to lethal and disabling diseases in children and adults. By continuing to allow politicians, celebrities and crackpots to spew utter nonsense about vaccine dangers the medical, scientific and media communities are complicit in compromising the health of the public both in the U.S. and worldwide.  Vaccines do have risks as do every other health intervention from alternative medicine, to aspirin, to anesthesia.  But, vaccines are among the safest and most effective tools we have to fight dread diseases.  The public should know that and hopefully my challenge to Bachmann will help make that happen.”
Ugly situation indeed, but if it results in a better understanding of vaccines, including their minimal risk in the face of major benefits, it will lead to a prettier picture of public health.