Polio Diagnosis and Other Factors

Last time we went over a brief history of the polio vaccine and the disease itself. This time we’re going to focus on some of the diagnostic issues and some other factors that may have contributed to the increase in polio cases.

 

What is AFP?

Before moving on, let’s look closer at the paralysis caused by polio. Specifically it is called acute flaccid paralysis (AFP), and it’s a term which describes the weakening or paralysis of a muscle and/or loss of muscle tone. Polio is not the only cause. It can be caused be several different things. In fact, Marx et al compiled a list of 26 possible causes of AFP.(1)

Here is a list of possible causes for AFP:

1)      Poliomyelitis
2)      Enterovirus (non-polio)
3)      VAPP (vaccine associated paralytic poliomyelitis)
4)      Rabies virus
5)      Varicella-zoster virus
6)      Japanese encephalitis virus
7)      Guillain-Barre syndrome
         a)      Acute inflammatory polyradiculoneuropathy
         b)      Acute motor axonal neuropathy
         c)      Cytomegalovirus polyradiculomyelopathy
8)      Intramuscular gluteal injection
9)      Acute transverse myelitis
10)  Epidural abscess
11)  Spinal cord compression; trauma
12)  Exotoxin of Corynebacterium diphtheriae
13)  Toxin of Clostridium botulinum
14)  Karwinskia humboldtiana, K. calderoni
15)  Tick bite paralysis
16)  Lyme borreliosis
17)  Myasthenia gravis
18)  Nondepolarizing drugs
19)  Polymyositis
20)  Viral myositis
21)  Trichinosis
22)  Toxic myopathies
23)  Hypokalemic periodic paralysis
24)  Gossypol, licorice
25)  Critical illness polyneuropathy
26)  Thick filament myopathy

 

Diagnostic/Data Problems in the US

Why does it matter that AFP has other causes? It has to do with diagnosis of polio, and how that can affect the perceived effectiveness of a vaccine. In order to accurately assess the effectiveness of the polio vaccine, we need to know how many cases there were before the vaccine was introduced, and how many there are after. The CDC would have you believe that we have this information. But unfortunately if we actually look closely, we find that we do not. Sure we have numbers of reported cases, but the problem lies with the diagnosis of the disease, and how the diagnosis criteria changed from pre 1954, to post 1961. Let’s take a look at some of these diagnostic issues.

 

How were cases of polio counted before and during 1954? The diagnostic criteria were based on the WHO definition at the time:

“A patient is considered clinically to have poliomyelitis for purposes of notification if the symptoms and signs correspond with the following descriptions:

            (a) Non-paralytic poliomyelitis

An illness characterized by fever, headache, vomiting, sore throat, listlessness, stiffness of neck and pack; pains in the back, neck trunk, or limbs, and hyperaesthesia; cerebrospinal fluid changes are usually found. The diagnosis is often strongly supported by epidemiological evidence; for example, known contact with a paralytic case or residence in an epidemic area.

            (b) Spinal paralytic poliomyelitis  

Signs and symptoms of non-paralytic poliomyelitis with the addition of partial or complete paralysis of one or more muscle groups, detected on two examinations at least 24 hours apart.”(2)

Here’s another source:

“There has been a decided shift in clinical concepts during the past twenty-five years as to what constitutes a case of poliomyelitis. For instance, more cases of non-paralytic poliomyelitis are so designated in the 1930’s and 1940’s than was the situation in the 1920’s. But, on the other hand, it has become increasingly difficult to define a case of non-paralytic poliomyelitis. For instance, in the present day when extensive muscle testing is performed, transient weaknesses lasting only a day or two have been designated as “paralytic cases” and thus the problem of definition has again shifted with a tendency for an increase in the relative percentage of paralytic cases.(emphasis added)”(3)

So all it takes for a diagnosis of polio in 1954 was partial paralysis of a muscle group tested twice at least 24 hours apart accompanied by signs and symptoms of nonparalytic poliomyelitis. Now the CDC has already said concerning nonparalytic poliomyelitis: “These syndromes are indistinguishable from other viral illnesses.”(4)

How about in 1955? What were the diagnostic criteria used?

“In 1955 the criteria were changed to conform more closely to the definition used in the 1954 field trials:residual paralysis was determined 10 to 20 days after onset of illness and again 50 to 70 days after onset”. (5)

That’s a big change in diagnostic criteria. We’ve already seen from the CDC that “Many persons with paralytic poliomyelitis recover completely and, in most, muscle function returns to some degree.”(4)By changing the diagnostic criteria from paralysis 24 hours apart, to 2 months apart, they have pretty much guaranteed that the number of paralytic polio cases would decrease, regardless of whether the vaccine was used or not.

Here’s an interesting quote from Paul Meier, a statistician who has written on the 1954 Salk trials, which affirms the over diagnosis of polio:

Next, we said, the diagnosis of polio is tricky, but we need to have the entire country’s physicians participate, because we can’t look over every case where there’s some kind of paralysis. So physicians reported the cases they thought were polio according to the protocol, and we accepted those cases. Now about half those cases were probably not polio at all, but still, we did have total reported cases, compared with paralytic and nonparalytic cases.”(6)

Now by 1960, how is poliomyelitis diagnosed? By this time in order for a diagnosis to be confirmed as polio, there must be a positive virus test on a stool sample.

“The diagnosis is made by identifying poliovirus in clinical specimens (usually stool) obtained from an acutely ill patient.”(7)

Below you’ll find a chart of reported cases of paralytic poliomyelitis by year from the CDC.

 

Year Total Paralytic
1954 38,476 18,308
1955 28,985 13,850
1956 15140 7,911
1957 5485 2499
1958 5787 3697
1959 8425 6289
1960 3190 2525
1961 1312 988

There are a couple of things to be aware of in this chart. From 1955 to 1960, only the Salk vaccine was being used. This was a killed virus vaccine. In 1961, the Sabin oral polio vaccine was introduced, which quickly replaced the IPV. If you look closely at this data, you’ll find that from 1957 to 1958, there is a 48% increase in paralytic cases reported. Between 1958 and 1959, there is another 70% increase in paralytic cases reported!

Due to the drastic change in diagnostic criteria, comparing the pre 1954 polio numbers to the post 1961 numbers is dishonest. You’re comparing apples and oranges. Yet this is exactly what the mainstream medical community does. They use these numbers to demonstrate how amazing mass vaccination campaigns are. To get an accurate view of the polio vaccine, we need to do one of two things. Either we need to compare pre-vaccine numbers to current levels that include all causes of AFP, or we can only look at data after 1961 to assess the effectiveness of the vaccine.

AFP Today

We’ve already gone over the fact that there are 25 other causes of AFP, other than the wild polio virus, so in order to make a valid comparison, it would be nice if we could compare the total number of cases of AFP that occurs today to the number of polio cases diagnosed in the pre-vaccine era. This is easier said than done, because a lot of these causes aren’t tracked, so nobody knows how prevalant they may be. Take tick paralysis as an example.

“There is no national surveillance system for tick paralysis and reliable information on incidence does not exist”(8)

Nevertheless, let’s look at a few examples of the other causes in order to get a general idea of the scope of the issue.

Guillain-Barre syndromeThe annual incidence globally is 1-2 per 100,000 population.(1) The incident rate really varies by age from .62 to 2.66 per 100,000.(9) The current US population is estimated to be about 316 million. So for Guillain-Barre syndrome, there are between 3160 and 6320 new cases every year. A study done in 2003 suggested that the symptoms exhibited by Franklin Delano Roosevelt, who was thought to suffer from poliomyelitis, were more likely to be Guillain-Barre syndrome.

The diagnosis at the onset of the illness and thereafter was paralytic poliomyelitis. Yet his age and many features of the illness are more consistent with a diagnosis of Guillain-Barré syndrome”(10)

Acute transverse myelitis – There are 1,400 new cases of transverse myelitis diagnosed each year in the United States.(11)

Myasthenia gravis – There are estimated to be between 3 and 30 new cases of myasthenia gravis per million population every year. McGrogan et al said “However, it is thought that the rates at the upper end of this range, reported by the prospective studies, provided the most accurate estimates.”(12) So 30 cases per million is likely the more accurate number. In the US, that would be between 948 and 9480 new cases every year.

 

BOX 1It is interesting to note that the cited list of AFP causes may not be exhaustive. That study which was done in the year 2000 does not mention West Nile virus, which is now known to cause a polio-like illness in some infected individuals. The incident rate of neuroinvasive disease from West Nile Virus varies by state.   There are 3 states with a greater than 1 in 100,000 incidence, and 10 more states with an incidence between 0.25 and 0.99 per 100,000.(13) It is unclear how many of these neuroinvasive West Nile cases resulted in AFP.West Nile Virus Neuroinvasive Disease Incidence by State – United States, 2013

AFPMap

 

If we add up just the three causes of Guillain-Barre syndrome, acute transverse myelitis, and myasthenia gravis, we get the annual incidence of AFP in the US to be 5508 – 17200. That doesn’t include the other 22 causes of non-polio AFP listed in the 2000 study, or the cases of AFP caused by West Nile virus! I’m not claiming that all of these cases of acute flaccid paralysis would have been diagnosed as polio, but it is reasonable to believe that the majority of the cases could have been.

We can’t come to any solid conclusions about the effectiveness of the polio vaccine for getting rid of polio based on this data. However, we can say that based on the diagnostic criteria in 1954, ‘polio’ still exists today.

Worldwide polio and AFP

We’ve seen how the lack of consistent diagnostic criteria in the US has led to a huge difficulty in assessing the true effectiveness of the polio vaccine. So what about worldwide data? Surely we can get more accurate numbers to evaluate the vaccine by looking at the cases in vaccine programs around the world. Alas, that is not the case. Doctors used lameness surveys, looking for people with deformed or shriveled legs, presuming that such problems were caused by polio, and then extrapolated that data to cover the surrounding areas which weren’t directly surveyed. Here is a case definition for the lameness surveys:

“The case definition used most frequently consists of (1) flaccid paralysis with atrophy, (2) no decrease in sensation, and (3) a history of acute onset with no subsequent progression of disease.”(14)

This source also states

“Some variation is to be expected, but the specificity of the case definition is a reasonable concern. Also, the case definition has not been applied uniformly.”(14)

And here is the WHO’s recommended surveillance standard:

“Highly sensitive surveillance for acute flaccid paralysis (AFP), including immediate case investigation, and specimen collection are critical for the detection of wild poliovirus circulation with the ultimate objective of polio eradication.”(15)

What the WHO and the lameness surveys do is try to ascertain all cases of acute flaccid paralysis, with the reasoning that polio will be a part of that group, and so they can target that area for vaccination programs. This is very similar to what happened in the US, in that we start with all cases of AFP, rather than just cases due to polio, so we can’t compare data from these surveys to outcomes of the vaccination programs.

According to the WHO:

“In 1988, when the Global Polio Eradication Initiative began, polio paralysed more than 1000 children worldwide every day.”(16)

That means that polio paralyzed over 350,000 kids every year! This statistic has been called into question however. In 2007, Dr. Jacob Puliyel, head of pediatrics at St Stephens hospital in Delhi said:

“WHO claims five million children have been saved from polio paralysis. It is instructive to see how this figure is arrived at. In 1988, there were 32,419 cases of paralytic poliomyelitis. The WHO arbitrarily raised this number ten-fold to 350,000 claiming incomplete reporting. In 2004 with the changed definition, only culture positive paralysis was considered polio and there were 2000 such cases. Subtracting 2000 from 350,000, the WHO calculated that 348,000 children were saved from paralysis that year.”(17)

The WHO has done a nice job of monitoring cases of polio and AFP in several countries since 1996. So let’s take a look at an example of the effectiveness of these worldwide polio eradication campaigns. (18)

AFPIndia

What the heck is going on with this huge increase in AFP? It looks like polio was finally eradicated in 2012, but what would it look like if they used the same lameness surveys as outcome markers for their campaign? Again, Puliyel examines this situation in 2012 in the Indian Journal of Medical Ethics:

“It has been reported in the Lancet that the incidence of AFP, especially non-polio AFP has increased exponentially in India after a high potency polio vaccine was introduced (25).  Grassly and colleagues suggested, at that time, that the increase in AFP was the result of a deliberate effort to intensify surveillance and reporting in India (26).   The National Polio Surveillance Programme maintained that the increased numbers were due to reporting of mild weakness, presumably weakness of little consequence (27).  However in 2005, a fifth of the cases of non-polio AFP in the Indian state of Uttar Pradesh (UP) were followed up after 60 days.  35.2% were found to have residual paralysis and 8.5% had died (making the total of residual paralysis or death – 43.7%) (28). Sathyamala examined data from the following year and showed that children who were identified with non-polio AFP were at more than twice the risk of dying than those with wild polio infection (27).”(19)

So Dr. Puliyel points out that the increase in AFP is not due to better surveillance that picked up more cases of mild weakness, as had been claimed, but rather these AFP cases are even more deadly than wild polio. Puliyel goes on to say:

“Data from India on polio control over 10 years, available from the National Polio Surveillance Project, has now been compiled and made available online for it to be scrutinised  by epidemiologists and statisticians (29). This shows that the non-polio AFP rate increases in proportion to the number of polio vaccine doses received in each area.”(19)

There are a couple of takeaways from this assessment. Non-polio AFP seems to be twice as deadly as paralytic polio, and cases of non-polio AFP go up in relation to the number of polio vaccines received. It is beyond the scope of this book to look into the reasons for this. However, this will hopefully serve as a reminder to us all that disease control is typically not a single factor issue. If we look at the US, we see that polio disappeared rather quickly especially compared to developing countries. We should not underestimate the role that sanitation plays in the control and eradication of disease.

Data from 1961 to the present

So we’ve seen that it is impossible to make a good comparison by using data from 1954 and prior. Even during the rest of the 1950’s, it may be difficult to trust the data. Observer bias can greatly affect the reported cases. For example, if you’re a doctor during this time period, and you’re told that the vaccine is 80-90% effective at preventing paralytic polio, then what do you do when you examine somebody who is exhibiting signs of paralytic polio (acute flaccid paralysis). The first thing you would likely do is to ask them if they received the polio vaccine. If they say yes, and you believe in the effectiveness of the vaccine, you would likely come up with a different diagnosis.

“In fact, I am certain that many health officers and physicians here will ask routinely if a child has been vaccinated when signs of poliomyelitis are present during the summer months. We have been conditioned today to screen out false positive cases in a way that was not even imagined prior to 1954”(5)

This is one of the reasons why it is imperative for us to only compare confirmed cases of polio. By 1960, testing for the poliovirus in stool samples was required in order for a case to be confirmed as polio.

Year Total Cases ParalyticCases
1979 34 26
1978 15 9
1977 18 17
1976 14 12
1975 8 8
1974 7 7
1973 8 7
1972 31 29
1971 21 17
1970 33 31
1969 20 18
1968 53 53
1967 41 40
1966 113 106
1965 72 61
1964 122 106
1963 449 396
1962 910 762
1961 1312 988
1960 3190 2525

Ignoring the possibility that some of these paralytic cases were in fact VAPP (paralysis caused by the vaccine), let’s assume that these were all confirmed cases of wild polio. Using this data, the best case scenario for the vaccine would be that it was able to reduce paralytic polio from 2525 cases per year to zero. That’s still pretty good, but it’s about 12% of the number that is typically cited by the CDC:

“Polio reached a peak in the United States in 1952, with more than 21,000 paralytic cases.”(4)

It’s definitely possible that the number of paralytic cases prevented by the vaccine is higher than this, however it’s difficult to have any confidence in the data prior to the polio cases being confirmed via testing of stool samples. Even though it’s not nearly as impressive as is often stated, it does appear that the polio vaccine was effective at getting rid of polio. However, before we come to any conclusions, it would be wise to further explore any other factors which may have played a role in the sudden appearance of epidemics of poliomyelitis.

What other factors may be linked to the rise in polio in the 20th century?

We’ve already gone over the sanitation theory, which is the main argument for the epidemics of polio we experienced in the mid 20th century. We’ve also seen how the sanitation theory fails to explain why developing countries began to experience epidemics of polio despite any advancements in their sanitation. So what are some other factors that may help to explain the sudden increase in paralytic polio?

Provocation Polio

There are several studies that point to something called provocation polio.(1, 20-24) Basically what they say is that getting an intramuscular injection while having a polio infection can cause a relatively benign infection to become paralytic. The virus will typically multiply in the nose, throat, and GI system without causing any symptoms. Normally, this type of infection will lead to immunity to the polio virus. However, if a muscular injury is sustained during this time, specifically a medical injection, it can cause the polio virus to spread to the central nervous system (CNS). The reason for this is that the injection causes retrograde axonal transport to occur, which then facilitates invasion of the CNS by the polo virus. A study was done in 1998 by Gromeier and Wimmer, trying to simulate provocation poliomyelitis in mice.

“Muscle injury due to injection of vaccines or therapeutic agents is common in medical practice. It has been observed that, if concurrent with PV infection, such injury may increase the risk of neurological complications …we have shown that muscular trauma induced by multiple injections can lead to rapid progression of PV-induced paralysis”(24)

Looking back on the data from 1957-1959, there was a 48% increase of paralytic polio cases reported between 1957 and 1958, and another 70% increase between 1958 and 1959. Was this increase caused by the polio vaccine? I believe that the Salk vaccine likely contributed to the increase in polio, because it was administered via an injection, and thus caused provocation polio. However it was not necessarily (except for the Cutter Incident) the ingredients in the vaccine that caused the increase. Wild-polio was still circulating widely at the time, and the mass vaccination programs created a lot of muscular trauma. This is why we don’t have an increase in polio today even though we’ve been using the injected IPV since 2000. There is no circulating polio virus.

The thing to remember is that it doesn’t have to be injection with the polio vaccine to cause this provocation polio. It can be any injection, whether it be another vaccine, antibiotics, medications, or whatever. In fact, if we look at history, we find that the diphtheria and pertussis vaccines were introduced and recommended in the 1940’s. And by the mid 1940’s they were in regular use.

Per the CDC’s pinkbook chapter on Pertussis:

“[Pertussis vaccine] was developed in the 1930s and used widely in clinical practice by the mid-1940s.” (25)

 polio1

As we can see from this graph, cases of polio were steadily rising in the 1940’s.

 polio2

It’s a little bit easier to visualize the steady rise in polio cases in the above graph. Unfortunately, before 1951 polio cases were not separated into paralytic and non-paralytic cases, so we’re unable to get a more accurate view of the effects of these other vaccines on paralytic cases. Several studies(26-28) have been done which corroborate the fact that the risk of paralysis is greater following some sort of injection. Here’s an excerpt from one such study:

“Seventeen cases are described in which paralysis of a single limb has occurred within 28 days of receiving an injection. Of these fifteen followed immunization and two penicillin.”(28)

 

Another study by Greenberg et al, demonstrates this concept very well:

“This investigation corroborates the published findings of other investigators that there is a relationship between recent inoculation with diphtheria toxoid, tetanus toxoid or pertussis vaccine (DPT) and the development of paralytic poliomyelitis.”(29)

Tonsillectomy

Anybody familiar with the polio scare back in the mid 20th century will surely think of the iron lung. The iron lung was used for those people who suffered from the most severe type of polio infection called bulbar polio.   This occurs when the polio virus makes its way to the brain stem, which can lead to difficulties speaking, swallowing and breathing, and can ultimately result in death. Having your tonsils removed has been shown to significantly increase your risk for developing bulbar polio. For a long time, tonsils were thought of as being nothing more than vestigial organs that the body no longer needed. They were taken out on a whim. It is a little bit less common today than it was back in the mid 20th century, but it is still a fairly common procedure.(30)

There are quite a few sources supporting this idea that tonsillectomy contributes to a higher risk of developing bulbar polio.(31-35) In fact in 1938, Albert Sabin, replicated bulbar polio in monkeys who had received a tonsillectomy. (31)

From the American Journal of Public Health, we find this:

“The results of these studies are singularly consistent in demonstrating that a history of tonsillectomy is from two to three times more frequent in patients with bulbar than it is with patients having spinal or nonparalytic poliomyelitis.”(35)

Writing about the pros and cons of tonsillectomy, AH Gale had this to say:

“But a more important matter is that of the possible association between tonsillectomy and poliomyelitis of severe bulbar type. Everyone has heard of the five children of one family in Akron, Ohio, who had their tonsils removed in August, 1941, and all developed bulbar poliomyelitis, of which three died. The sixth and youngest child, who was not operated upon, did not develop poliomyelitis, although excreting poliomyelitis virus in the faeces.”(36)

And just how common were tonsillectomies?

“Between 1915 and the 1960s, [tonsillectomy/adenoidectomy] was the most frequently performed surgical procedure in the United States.”(37)

“In 1959, 1.4 million tonsillectomies were performed in the United States. This number had dropped to 260,000 by 1987, when it was the 24th most common indication for hospital admission”(30)

Environmental Toxins

There is a theory (the toxin theory/DDT theory) which postulates that cases of poliomyelitis may actually have been caused by exposure to pesticides such as DDT, and had nothing to do with the polio virus. The problem with this theory is that it fails to account for the reduction in poliomyelitis cases following the introduction of the vaccine, and prior to DDT being banned in the United States. On the other hand, the viral theory (the idea that the polio virus is the sole cause of poliomyelitis) fails to explain why prior to the 19th century, epidemics of poliomyelitis were practically unheard of, even though the polio virus was highly endemic in humans. Instead there is intriguing evidence that insecticides such as DDT and the lead arsenate used before it, were important co-factors in the development of epidemics of paralytic polio. It was environmental toxins combined with the circulating virus which ended up causing these epidemics of polio. There is a lot of information to digest with this theory, and Dan Olmstead and Mark Blaxill do an excellent job of breaking it down.(38) I highly recommend taking the time to read through their presentation in it’s entirety. Below is an interesting graph from their presentation:

polioDDT

Dr. Morton Biskind had early concerns about DDT, and stated in 1950:

“… it is known that not only can DDT poisoning produce a condition that may easily be mistaken for polio in an epidemic but also being a nerve poison itself, may damage cells in the spinal cord and thus increase the susceptibility to the virus.”(39)

There is some evidence that shows exposure to DDT may increase the replication of the polio virus. Janis Gabliks looked at the replication effects of various insecticide compounds on the vaccinia and polio viruses:

“In the poliovirus tests the cell response was not uniform. In comparison to the controls the virus yield in the DDT-treated cultures was slightly increased”(40)

Olmstead and Blaxillbelieve it was a different mechanism than that stated by Dr Biskind, which caused the increasing polio epidemics:

“… our fundamental idea is that both the poliovirus and the pesticide enter the body by the same route — they are ingested — and both end up in the stomach. There, the toxin could damage the stomach lining in such a way that the virus gains access to peripheral nerves. This kind of virus-toxin interaction (perhaps with arsenic or lead acting alone as the toxin) took place sporadically before 1890 and increased dramatically, we propose, with the invention of more potent insecticides like lead arsenate. With the advent of DDT, the interaction became even more dangerous, dramatically increasing the number of cases.”(38)

Regardless of the causative mechanism, more research needs to be done in this area in order to come to a better understanding of the role of environmental toxins, such as lead arsenate and DDT, on the emergence of poliomyelitis epidemics.

From the preceding information, it seems pretty clear that multiple factors were involved in the sudden emergence of poliomyelitis epidemics. An interesting question that remains to be answered is what would happen to the prevalence of paralytic polio infections, if all of the other risk factors besides the virus were eliminated? We know that before the 20th century, these epidemics were pretty much unheard of, so was the chance of a paralytic infection during this time period still 1 in 200 cases? I’m inclined to believe that without being exposed to these other risk factors, the chance of a paralytic infection is probably much lower. To my knowledge, no study has been done to examine this idea, and I doubt one will be done anytime soon given the fact that the poliovirus has been eradicated from the Western Hemisphere.

References:

(1)      Differential Diagnosis of Acute Flaccid Paralysis and Its Role in Poliomyelitis Surveillance, Arthur Marx, Jonathan D. Glass, and Roland W. Sutter. Epidemiologic Reviews, Vol. 22, No. 2, 2000. http://epirev.oxfordjournals.org/cgi/reprint/22/2/298.pdf

(2)     http://whqlibdoc.who.int/monograph/WHO_MONO_26_%28part5%29.pdf

(3)     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598936/pdf/yjbm00342-0025.pdf

Yale Journal of Biology and Medicine p 327-340 Julian Irving Pichel

Yale J Biol Med. 1950 March; 22(4): 327–340.

(4)     Epidemiology and Prevention of Vaccine-Preventable Diseases, The Pink Book: Course Textbook, 11th Edition (May 2009), Chapter 16, Poliomyelitis. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/polio.pdf

(5)     The Present Status of Polio Vaccines (a panel discussion), Illinois Medical Journal, August, 1960.

(6)     A Conversation with Paul Meier, Harry M. Marks. Clinical Trials 2004, 1, 131. http://www.hopkinsmedicine.org/histmed/people/faculty/papers/meier.pdf

(7)     http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/poliomyelitis

(8)     http://www.uptodate.com/contents/tick-paralysis

(9)     http://www.karger.com/Article/Pdf/324710

(10)  Goldman.2003.”What was the cause of Franklin Delano Roosevelt’s paralytic illness?” J Med Biog, 11:233-240.

http://www.ncbi.nlm.nih.gov/pubmed/14562158

(11)  http://www.ninds.nih.gov/disorders/transversemyelitis/detail_transversemyelitis.htm

(12)  http://www.ncbi.nlm.nih.gov/pubmed/20130418

(13)  http://www.cdc.gov/westnile/statsMaps/preliminaryMapsData/incidencestatedate.html

(14)  Some Observations on Poliomyelitis Lameness Surveys,  Roger H. Bernier,  Reviews of Infectious Diseases, Vol. 6, Supplement 2. International Symposium on Poliomyelitis Control (May – Jun., 1984), pp. S371-S375
http://www.jstor.org/pss/4453375

(15)  http://www.who.int/immunization_monitoring/diseases/poliomyelitis_surveillance/en/

(16)  http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx#sthash.QF9HFcWm.dpuf

(17)  Polio eradication & the future for other programmes: Situation analysis for strategic planning in India (Editorial), Jacob S. Puliyel, Manoj Anand Gupta, Joseph L. Mathew, Indian J Med Res 125, January 2007, pp 1-4 http://jacob.puliyel.com/download.php?id=132

(18)  WHO, Immunization Monitoring,  Diseases, Poliomyelitis Case Count, accessed multiple times between May 1 and June 1, 2010. http://apps.who.int/immunization_monitoring/en/diseases/poliomyelitis/case_count.cfm

(19)  http://www.issuesinmedicalethics.org/202co114.html                                   Indian J Med Ethics. 2012 Apr-Jun;9(2):114-7.Polio programme: let us declare          victory and move on.Vashisht N, Puliyel J.

(20)  The Relation Between Recent Injections and Paralytic Poliomyelitis in Children. Morris Greenberg, Harold Abramson, Helen M. Cooper and Helen E. Solomon. American Journal of Public Health, 1952, 42, 142-152. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525737/pdf/amjphnation00407-0031.pdf

(21)  Intramuscular Injections Within 30 Days of Immunization with Oral Poliovirus Vaccine – A Risk Factor for Vaccine-Associated Paralytic Poliomyelitis. Peter M. Strebel, Nicholae Ion-Nedelcu, Andrew L. Baughman, Roland W. Sutter, and Stephen I. Cochi. New England Journal of Medicine, 1995, 332, 8, 500-506.  http://www.nejm.org/doi/pdf/10.1056/NEJM199502233320804

(22)  Poliomyelitis: 20 years–the Pondicherry experience. Mahadevan S, Ananthakrishnan S, Srinivasan S, Nalini P, Puri RK, Badrinath S, Rao RS. The Journal of Tropical Medicine and Hygiene. 1989 Dec;92(6):416-21. http://www.ncbi.nlm.nih.gov/pubmed/2558226

(23)  Outbreak of poliomyelitis due to type 3 poliovirus, northern India, 1999–2000: injections a major contributing factor. Kathryn A Kohler, W Gary Hlady, Kaushik Banerjee and Roland W Sutter, International Journal of Epidemiology, 2003, 32, 272-277. http://ije.oxfordjournals.org/content/32/2/272.full.pdf+html

(24)  Mechanism of Injury-Provoked Poliomyelitis, Matthias Gromeier and Eckard Wimmer. Journal of Virology, June 1998, p. 5056-5060. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC110068/pdf/jv005056.pdf

(25)  http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pert.pdf

(26)  McCloskey BP. The relation of prophylactic inoculations to the onset of poliomyletis. Lancet, April 18, 1950:659–63.

(27)  Geffen DH. The incidence of paralysis occurring in London children within four weeks after immunization. Med Officer 1950;83:137–40.

(28)  Martin JK. Local paralysis in children after injections. Arch Dis Child 1950; 25:1–14.

(29)  The Relation Between Recent Injections and Paralytic Poliomyelitis in Children. Morris Greenberg, Harold Abramson, Helen M. Cooper and Helen E. Solomon. American Journal of Public Health, 1952, 42, 142-152. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525737/pdf/amjphnation00407-0031.pdf

(30)  http://emedicine.medscape.com/article/872119-overview

(31)  Experimental Poliomyelitis by the Tonsillopharyngeal Route: With Special Reference to the Influence of Tonsillectomy on the Development of Bulbar Poliomyelitis. Albert B. Sabin.J Am Med Assoc, Aug 1938; 111: 605 – 610. http://jama.ama-assn.org/cgi/content/summary/111/7/605

(32)  Studies on a Long Range Association Between Bulbar Poliomyelitis and Previous Tonsillectomy. R. V. Southcott. The Medical Journal Of Australia. 1953. Aug 22;2(8):281-98. http://www.ncbi.nlm.nih.gov/pubmed/13098558

(33)  Occurrence of Poliomyelitis in Relation to Tonsillectomies at Various Intervals. Franklin H. Top. Journal of the American Medical Association. 1952, 150(6) 534-538. http://jama.ama-assn.org/cgi/content/summary/150/6/534

(34)  Absence of Tonsils as a Factor in the Development of Bulbar Poliomyelitis, Gaylord W. Anderson, Jeanne L. Rondeau. The Journal of the American Medical Association, 1954, 155 (13) 1123-1130. http://www.ncbi.nlm.nih.gov/pubmed/13174358

(35)  Tonsillectomy and Poliomyelitis. American Journal of Public Health, 1954, 44 (8) 1065-1067. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1620872/pdf/amjphnation00361-0092.pdf

(36)  “Pros and cons of Tonsillectomy” A. H. Gale. BMJ 1951, 20 January. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2068074/?page=1

(37)  http://jhmas.oxfordjournals.org/content/62/4/383.abstract

(38)  http://www.ageofautism.com/2011/09/the-age-of-polio-how-an-old-virus-and-new-toxins-triggered-a-man-made-epidemic-1.html

(39)  Morris S. Biskind, M.D., “Statement on Clinical Intoxication From DDT and Other New Insecticides, Presented before the Select Committee to Investigate the Use of Chemicals in Food Products, United States House of Representatives, December 12, 1950.” Journal of Insurance Medicine, May 1951.

(40)  Arch Environ Health. 1967 May;14(5):698-702.Insecticidal compounds. Effects on replication of vaccinia and polio viruses in human chang-strain liver cells. Gabliks J.

 

 

History of Polio and the Two Polio Vaccines

Tags

, , ,

This is the first in a 3 part series on polio. In this post I will cover basic information and history of the disease, as well as the early history of the polio vaccine.  To me, understanding the disease is extremely important, because how can we know if a vaccine is beneficial or not if we don’t have an accurate view of the disease it’s supposed to protect against?

The common line of thought in mainstream medicine is that polio was a horrible disease which afflicted many people in the early to mid 20th century. It was so rampant that even one of the most beloved presidents, Franklin Delano Roosevelt, was thought to have suffered from this disease. When a vaccine was produced for polio, it was deemed a miracle. Finally there would be an end to all these countless cases of paralysis sweeping through the country. The CDC tells us that the vaccine proved to be very effective, and is heralded as one of the best examples of how vaccines are our salvation from these horrible childhood diseases. Here is a common sentiment among the pro-vaccine crowd: 

If you read enough pro-vaccine articles, you’ll start to see the common assertion that we need to vaccinate so we can eradicate the disease, just like we got rid of polio. To many it seems pretty clear that the polio vaccine was a great achievement in medicine, and it is used as justification to push every other vaccination. I hate this argument, specifically because it encourages a rash generalization of all vaccines being equivalent. They are far from being equal, and it is my belief that each disease/vaccine needs to be evaluated on its own.

What is Polio?

The first thing we need to do is find out more about the disease that we’re trying to protect against. How can we know how effective and beneficial a vaccine has been, unless we know how bad the disease was? From the World Health Organization, we get this:

“Polio is a highly infectious disease caused by a virus. It invades the nervous system, and can cause total paralysis in a matter of hours. The virus enters the body through the mouth and multiplies in the intestine. Initial symptoms are fever, fatigue, headache, vomiting, stiffness in the neck and pain in the limbs.”(1)

Polio virus is transmitted via fecal-oral, oral-oral, or occasionally through a common vehicle such as a shared drink.There are actually three strains of polio virus, and you can technically get polio three times, because immunity to one strain does not confer immunity to the others. The most common outcome when a person is exposed to the wild polio virus is asymptomatic infection (~72%). What about the other 28%? What sort of symptoms do they get? 24% get abortive poliomyelitis, which is a minor illness. And 4% get non-paralytic poliomyelitis, which can include aseptic meningitis.(2)

According to the CDC, the clinical picture is even better:

“Up to 95% of all polio infections are inapparent or asymptomatic.”

“Approximately 4%-8% of polio infections consist of a minor, nonspecific illness without clinical or laboratory evidence of central nervous system invasion. This clinical presentation is known as abortive poliomyelitis, and is characterized by complete recovery in less than a week. Three syndromes observed with this form of poliovirus infection are upper respiratory tract infection (sore throat and fever), gastrointestinal disturbances (nausea, vomiting abdominal pain, constipation or, rarely, diarrhea) and influenza-like illness. These syndromes are indistinguishable from other viral illnesses.

“Nonparalytic aseptic meningitis (symptoms of stiffness of the neck, back, and/or legs), usually following several days after a prodrome similar to that of minor illness, occurs in 1%-2% of polio infections. Increased or abnormal sensations can also occur. Typically these symptoms will last 2 to 10 days, followed by complete recovery.”(3)

So the vast majority of polio infections will have no residual effects, and complete recovery is expected. In fact, up to 95% will be either asymptomatic, or a minor illness. The main reason for a vaccine seems to be to prevent the paralytic consequences of infection. Well just how often does paralysis occur?

“Only 1/1,000 to 1/100 infected individuals develop paralytic disease (28-30). Reports of greater ratios of paralytic infection to subclinical infection in poliomyelitis are not based on consistent case ascertainment, or are not representative of the range in the majority of literature reports.” (2)

“Up to 95% of all polio infections are inapparent or asymptomatic. Estimates of the ratio of inapparent to paralytic illness vary from 50:1 to 1,000:1 (usually 200:1). Infected persons without symptoms shed virus in the stool and are able to transmit the virus to others.”(3)

These sources both confirm that the estimates of paralytic infection may vary, but 1/200 is the generally accepted estimate. So if your child is infected with the polio virus, there is a 0.5% chance that they will get a paralytic infection. Put another way, there is a 99.5% chance that they will not have a paralytic infection. Still, from a public health standpoint, 1 case in 200 infections is a fair amount. And according to the CDC, in the pre-vaccine era there were an estimated 3 to 4 million infections per year, which equates to 15000 – 20,000 paralytic cases per year just in the US.

“Many persons with paralytic poliomyelitis recover completely and, in most, muscle function returns to some degree. Weakness or paralysis still present 12 months after onset is usually permanent.”(3)

Now we find that even in paralytic cases, it’s not typically permanent.

“The illness progresses to flaccid paralysis with diminished deep tendon reflexes, reaches a plateau without change for days to weeks, and is usually asymmetrical. Strength then begins to return.”(3)

Again, the CDC reaffirms that in paralytic cases, the paralysis is often not permanent.  After as little as days, strength can start to return. This fact is going to be useful for us to remember as we look into the history and diagnosis of polio.

HISTORY OF DISEASE/VACCINE

Early History of Polio

Was polio always such a problem to society? When we look at the literature, we find that polio was a relatively benign disease prior to the 20th century, with only rare instances of paralytic infections. The CDC states:

“Before the 18th century, polioviruses probably circulated widely. Initial infections with at least one type probably occurred in early infancy, when transplacentally acquired maternal antibodies were high. Exposure throughout life probably provided continual boosting of immunity, and paralytic infections were probably rare.

In the immediate prevaccine era, improved sanitation allowed less frequent exposure and increased the age of primary infection. Boosting of immunity from natural exposure became more infrequent and the number of susceptible persons accumulated, ultimately resulting in the occurrence of epidemics, with 13,000 to 20,000 paralytic cases reported annually.”(3)

I want to point out that this excerpt from the CDC pinkbook mentions the sanitation theory, which we will come back to a little later. The CDC goes on to say:

“In the early vaccine era, the incidence dramatically decreased after the introduction of inactivated polio vaccine (IPV) in 1955. The decline continued following oral polio vaccine (OPV) introduction in 1961. In 1960, a total of 2,525 paralytic cases were reported, compared with 61 in 1965.”(3)

A few other sources corroborate the fact that polio prior to the 20th century was a much different disease:

“In reviewing this subject briefly, one finds that at the turn of the century, “infantile paralysis,” as it was then called, was considered to be “rather rare after the age of six.” Indeed more than 50 per cent of the cases were under two years of age.”(4)

“Early records (1900-1920) are scanty, in fact poliomyelitis did not become a reportable disease in Connecticut until 1916. Not until 1920 did the reports become adequate for analysis. Consequently the study was limited to the period from 1921 to 1947.”(4)

This is what the World Health Organization (WHO) had to say:

“The history of poliomyelitis suggests that in the first half of the 19th century the clinical disease was rare and largely restricted to infants, while epidemics were almost unknown.”(5)

So to summarize, the CDC and various other sources say that before the turn of the century, paralytic infections were probably rare, but for some reason we find a dramatic rise in paralytic cases in the early to mid 20th century. The CDC states that this is likely due to the sanitation theory. They then go on to talk about the dramatic decline in paralytic cases after the introduction of the vaccines. It seems pretty straightforward so far.

History of Polio Vaccines

When looking at the development of the polio vaccines, there are quite a few details we could go over, but I feel that may be information overload for a lot of people. Instead I’m just going to give a brief overview of some main events.

In 1954 there was a massive polio vaccine trial which tested the Salk polio vaccine in 1.8 million children. The Salk vaccine was an inactivated polio vaccine (IPV) meaning that the virus was killed. In 1955, the results of this trial were reported and it was stated that the vaccine was 80-90% effective in protecting against paralytic polio. In 1955, the Salk vaccine was licensed in the US and mass vaccinations begun. An interesting tidbit on the Salk vaccine involves what is known as the Cutter Incident.

“In April 1955 more than 200 000 children in five Western and mid-Western USA states received a polio vaccine in which the process of inactivating the live virus proved to be defective. Within days there were reports of paralysis and within a month the first mass vaccination programme against polio had to be abandoned. Subsequent investigations revealed that the vaccine, manufactured by the California-based family firm of Cutter Laboratories, had caused 40 000 cases of polio, leaving 200 children with varying degrees of paralysis and killing 10.”(8)

This incident occurred in April of 1955, shortly after the Salk vaccine was licensed. The US Surgeon General recommended suspending all polio vaccines, and mass vaccinations didn’t begin again until the fall of 1955. The Sabin oral polio vaccine (OPV) was first licensed in 1961, but it wasn’t until 1963 when the trivalent vaccine was licensed. The OPV quickly replaced the IPV as the vaccine of choice in the United States.

Why the two different vaccines? Sabin was critical of Salk’s vaccine, because he didn’t think that a killed-virus vaccine would offer lasting immunity. Sabin’s approach was to use a vaccine with a live-attenuated virus. After Sabin did clinical trials on his vaccine in Russia, it was found that his oral polio vaccine was better than the IPV for several reasons. It conferred longer-lasting immunity, so booster shots were not necessary. It was taken orally, typically on a sugar cube, rather than having to be injected, so it was much easier to administer. But one of the most intriguing advantages of the Sabin vaccine was the concept of passive vaccination. People receiving the OPV would still develop an active infection and shed the virus in the stool, and it was thought that this would help protect people who had not received the vaccine.

By the mid to late 1960’s a risk of the Sabin vaccine was discovered. It was possible for the weakened virus in the OPV to cause paralytic polio. Despite this knowledge, use of the Sabin polio vaccine continued in the US until the year 2000, when it was replaced with the IPV, which does not cause paralysis. Apparently, health officials at the time thought that the benefits of the OPV outweighed the small risk of vaccine associated paralytic poliomyelitis (VAPP).

Sanitation Theory

The CDC makes mention of the sanitation theory as an explanation for why we saw a huge increase in paralytic cases in the 20th century. The sanitation theory is a paradoxical theory in that disease incidence rises with improved sanitation. This theory proposes that as sanitation practices became better in the developed countries, exposure to the polio virus as infants, when we were still protected by maternal antibodies, declined. This led to exposure to the virus later in life when we have less protection, and there is a higher likelihood of developing serious sequelae (paralysis). Although this theory does seem to explain why polio, which used to be considered a fairly benign disease with only rare cases of paralysis, started to become more and more serious, there is some doubt as to whether it is accurate.

This theory is based on data researched by Albert Sabin (the same guy who invented the oral polio vaccine).(6) He found that the rates of paralytic infection varied. During 1944 and 1945 in the Phillipines, the rate of paralytic infections was 88 and 43 per 100,000 amongst the American troops, and either no cases or very rare instances among the Filipino children. Another example comes from the statistics from Hawaii between 1938 and 1947. Rates of paralytic disease were 10.2 per 100,000 in the white population, and 1.3 per 100,000 in the Hawaiian population.(6) These and several other observations were made back in 1951, and one of the conclusions made by Sabin was

In general, the poorer the population, its standard of living and sanitation, the more extensively is poliomyelitis virus disseminated among them and the lower is the incidence of paralytic poliomyelitis when virulent strains of virus come their way.”(6)

Based on this theory, we should have been able to predict that areas with poorer sanitation will have fewer issues with epidemics of paralytic paralysis. However, we find that even in areas with poor sanitation, these groups of people who previously seemed to have low rates of paralytic poliomyelitis started to experience epidemics. An example is an outbreak in Leopoldville starting in 1958. “There has been . . . a rate of 19.4 cases per 100,000 inhabitants.” What were the sanitary conditions? From the same article, we read “people live in huts and shacks with few sanitary facilities.” In fact 73% of the housing used pit privies. There was no indoor plumbing.(7)

The mindset today in developing countries that still lack proper sanitation and yet are experiencing epidemics of polio is summed up nicely in a recent article from 2011:

“Environmentalists and health, water and sanitation experts were of the opinion that Pakistan’s efforts for polio eradication and achieving sustainable development goals are bound to fail, if access to safe sanitation in the country is not improved.”(9)

We find more evidence that epidemic polio started to occur in places which still lacked proper sanitation. According to the Global Polio Eradication Initiative:

“Lameness surveys during the 1970s revealed that the disease was also prevalent in developing countries.”(10)

So what happened? Were the earlier observations just wrong? Or did something happen to change the fact that developing countries that still lack proper sanitation were now experiencing polio epidemics where previously they had none? The actual data doesn’t seem to fit the sanitation theory very well. At the very least, sanitation is not the only factor that affects the prevalence of paralytic polio.

My next post will look at some of the other factors affecting the prevalence of paralytic polio, as well as some diagnostic issues surrounding polio and vaccination.

 

References:

(1)     World Health Organization. Media Centre. Fact Sheets. Poliomyelitis. http://www.who.int/mediacentre/factsheets/fs114/en

(2)      Differential Diagnosis of Acute Flaccid Paralysis and Its Role in Poliomyelitis Surveillance, Arthur Marx, Jonathan D. Glass, and Roland W. Sutter. Epidemiologic Reviews, Vol. 22, No. 2, 2000. http://epirev.oxfordjournals.org/cgi/reprint/22/2/298.pdf

(3)     Epidemiology and Prevention of Vaccine-Preventable Diseases, The Pink Book: Course Textbook, 11th Edition (May 2009), Chapter 16, Poliomyelitis. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/polio.pdf

(4)     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598936/pdf/yjbm00342-0025.pdf

(5)     http://whqlibdoc.who.int/monograph/WHO_MONO_26_%28part5%29.pdf

(6)     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525657/pdf/amjphnation00428-0010.pdf

(7)     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2555313/pdf/bullwho00332-0012.pdf

(8)     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1383764/

(9)     http://www.thenews.com.pk/Todays-News-6-143915-Polio-eradication-not-possible-sans-improving-sanitation-experts

(10)  http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx

 

Aside

Response to Violent Metaphors post

This post is in response to a blog post found here:

http://violentmetaphors.com/2014/03/25/parents-you-are-being-lied-to/

At first glance it seems like she provides a lot of links to back up her claims, but I wanted to go through them and see how well they stack up.

The initial thing that stands out for me with this blog article is that she says that people who are anti-vaccine are lying to you. To lie is to intentionally make a false statement, knowing that it is not the truth. She may disagree with the claims of people who question vaccines, but it is quite a jump to say that these people are lying. What would have given this article more credibility is if she had responded to some of the evidence put forth by ‘anti-vacciners’. Instead, all of her links are to things supporting her own position. Nowhere is there a response to evidence for the counter position. Now maybe she’s just not aware of any evidence, and maybe she believes that all of the ‘anti-vax’ claims are made-up with nothing to support those claims. It is quite easy to find studies and doctors in support of vaccination, and much more difficult to find the evidence to the contrary. But just because the pro-vaccine position is the majority, it doesn’t mean that it’s correct. The vast majority of studies on vaccines are conducted by pharmaceutical companies with a vested interest in the success of vaccines. But I won’t get into that right now. Instead I’ll address each of the things she says.

In light of recent outbreaks of measles and other vaccine preventable illnesses, and the refusal of anti-vaccination advocates to acknowledge the problem, I thought it was past time for this post.

Her first link is about measles outbreaks, and that is her reason for finally writing this post. Of all the vaccines out there I honestly think that measles is the easiest to defend from a pro-vaccine standpoint. This is because the measles vaccine is actually fairly effective, at least in the short-term, at protecting against measles. However, I would encourage you to read this link about measles and herd immunity.

In that link it talks about the waning immunity to measles because of the mass vaccination against the disease. When the vaccination was first introduced, it was able to piggyback on the existing natural immunity in most of the adult population. Now the older population is slowly being replaced by those who have only ever received the vaccine. This is an issue because even though the measles is touted as having up to 99% efficacy, that protection doesn’t always last too long. When it comes to the measles vaccine, there are high responders (about 25%), there are low responders (about 5%), and then there’s everybody else in between. The high responders are able to maintain titer levels above 1000 units after 10 years from vaccination. The low responders titer levels drop below 120 units after 10 years, and everybody else’s titer levels fall within the 120-1000 unit range. Obviously the low responders can contract measles, which is why we do see cases of measles in previously vaccinated individuals. But perhaps worse is that the majority of children (70%) with titer levels between 120 and 1000, can get a measles infection and potentially be contagious, but their infection may be modified and thus not labeled as measles. The increase in recent outbreaks may not be due to the unvaccinated population, but rather to the natural consequences of mass vaccination. More evidence that it may not be the unvaccinated causing the outbreaks is the fact that vaccination coverage for measles has been pretty much constant at 90% or above since 1996.

This link only covers through the year 2009, but if you really want to know, the vaccine coverage for children in 2010 was 91.5%, 2011 was 91.6%, and 2012 was 90.8%. That’s all the data I could find from the CDC.

Dear parents,

You are being lied to. The people who claim to be acting in the best interests of your children are putting their health and even lives at risk.

The first link in this statement is to an article about Dr. Bob Sears, the guy who wrote the vaccine book. It’s pretty common to see militant pro-vaccine people criticize Dr. Sears because of his suggested alternative schedule. In fact, we’ll see it as the focus in several more links in this blog post. I think it’s funny that he gets labeled as anti-vaccine, because I’ve read his book, and he is far from it. It amazes me how his position is completely lambasted by people. All he did was offer an alternative schedule for people who may worry about their children getting so many vaccines at once. The reason he does that is because he thinks that it will ease those parents’ fears and thus help them to get the vaccines for their kids. The article cited along with all the articles critical of Dr. Sears seem to have the underlying belief that if you don’t vaccinate on time according to the CDC vaccination schedule, then you are anti-vaccine. Most other countries in the world follow a vastly different schedule than the US, and most have less than half the number of mandatory vaccines. Are they anti-vaccine too?

The rest of the article linked to reveals the author’s lack of knowledge about the history of measles, or at least it reveals the spin she wants to put on it. Here is her modified version of history:

“In 1982, we were this close to eradicating “domestic” measles in the US. Vaccination uptake had brought the virus–and the complications, hospitalizations, and deaths–to an all-time low, almost to zero, and to domestic eradication in the USA. Elsewhere in the world, work remains. And then the outbreaks started to grow, hitting 220 in 2011 and 189 in 2013 in the USA, up from domestic eradication in 2000”

Interestingly, she leaves out the fact that there was a huge outbreak of measles between 1989 and 1991 due to secondary vaccine failure. There were 55,000 total cases during this 3 year period.

The second link goes to an article at weather.com. The majority of this article talks about the Andrew Wakefield issue, and pretty much blames the modern anti-vaccine movement on that one paper. I don’t know how this article demonstrates that people who don’t vaccinate are putting other peoples’ lives at risk, unless you consider this sentence as proof: “Recent outbreaks of preventable diseases show the damage done by refusing vaccines.” This is a statement that requires evidence to back it up, but none is provided. I can link to articles that say Obama is a muslim, but that doesn’t necessarily make it true. As I mentioned before, how are we to be sure that the small numbers of unvaccinated are causing these outbreaks of measles, and it’s not being spread by the waning immunity in the adult population who haven’t had a booster shot in decades? Remember the secondary vaccine failure in 1989-1991? Unlike naturally acquired immunity, the protection from the measles vaccine is not lifelong. I’d be willing to bet that the population of adults who haven’t had a measles booster in the past 10 years is much greater than the unvaccinated population.

They say that measles isn’t a deadly disease.
But it is.

Absolutely measles can be deadly, especially in the malnourished and those who are deficient in Vitamin A. This link is to the World Health Organization so that fact sheet for measles includes a bunch of poor malnourished kids. I’m not arguing against measles vaccinations for other parts of the world. I do question the usefulness of them when other factors like hygiene, sanitation, and nutrition are never addressed. But my kids live in sanitary conditions and are healthy, so I’m not afraid of them getting measles. I would encourage those who are not prepared for their children contracting measles to go ahead and get the vaccine. Of course what about the other children? Shouldn’t I subject my child to something I don’t agree with for the sake of other people I don’t know? No. I can guarantee that if any of my children are exposed to someone with measles, I will quarantine them even before they exhibit symptoms in order to prevent the transmission. And if they do get measles, then once it resolves, they will have lifelong immunity. I’m confident in my ability to help them through this sickness, which before the introduction of the vaccine was viewed as a common childhood illness.

They say that chickenpox isn’t that big of a deal.
But it can be.

Linking to a varicella page on the CDC website hardly shows how chickenpox can be a big deal. It is a mild self limiting disease. The vast majority of complications come not from chickenpox, but because of secondary bacterial infections. The common cold can lead to complications such as otitis media, sinusitis, bronchitis, and even pneumonia, yet people don’t tend to freak out about a cold. But I’m sure if a vaccine were created for the common cold, these people would use the same line of reasoning to force everybody to be vaccinated. There are some other issues I have with the chickenpox vaccine. Chickenpox and Shingles are caused by the same virus, and we’ll never be able to get rid of it. As more kids get vaccinated for chickenpox, the older population is going to be exposed to it less often. Without this exposure to bolster the immune system, we’re likely to see shingles begin to occur in younger and younger people.   People with shingles can then pass the virus to those who have never had it, and give them chickenpox. I say that we will never eradicate chickenpox because the vaccine itself can cause a dormant infection and give you shingles later. From the CDC:

“Chickenpox vaccines contain weakened live VZV, which may cause latent (dormant) infection. The vaccine-strain VZV can reactivate later in life and cause shingles.”

So unlike smallpox where the disease has been eradicated, and as a result we can stop vaccinating for it, we will never stop vaccinating for chickenpox. And I predict that as shingles becomes more and more prominent in younger individuals, there will be calls for more boosters throughout life. I’m sure the pharmaceutical companies are just fine with mandatory shingles shots every 10 years.

They say that the flu isn’t dangerous.
But it is.

Again she makes a statement, and instead of linking to a source that directly addresses the statement she makes, she instead links to the CDC’s basic information page about the flu. Saying that the flu isn’t dangerous would never be the argument I use against the flu vaccine, but I want to take a brief look at the data. The common number cited is that the flu causes 36,000 deaths per year. Read this for a good breakdown of why this number is ridiculous.

Basically there are really only about 500 deaths per year attributed to influenza, and the vast majority of these are probably not the flu. Only 15-20% of reported cases of influenza are actually caused by the flu virus. The other 80-85% is caused by flu-like viruses which the flu vaccine does nothing against. The 36,000 number comes from a computer simulation using the loose definition of influenza-associated death. So somebody who dies of some other cause after having the flu would be counted towards this number, even if it’s something that’s not really associated, such as a heart ailment. For an even more thorough breakdown of influenza, go here.

There has also been some recent research suggesting that getting the flu vaccine may actually increase your chances of getting other respiratory illnesses.

This study is amazing for a vaccine study, because they actually used a real saline injection placebo. There was no statistically significant difference between the groups in the risk of seasonal flu infection, but the vaccine recipients had a 4.4 relative risk for developing non-influenza respiratory infections. Obviously this study is small, and warrants follow-up research, but it doesn’t look good for the flu vaccine.

They say that whooping cough isn’t so bad for kids to get.
But it is.

This is another link to a CDC information page. There’s one statement on the CDC page that really stood out to me. “Many babies who get whooping cough are infected by parents, older siblings, or other caregivers who might not even know they have the disease.” Earlier they say that you should vaccinate yourself and family in order to protect your newborn baby from pertussis (whooping cough). This assumes that the vaccine prevents the transmission of the disease, which it does not. The pertussis vaccine contains antigens for the toxin that the pertussis vaccine excretes, but not for the bacteria itself. This means that the vaccine may decrease the symptoms from pertussis, but the bacteria can still be passed on. So the caregivers, parents, siblings who can pass on the disease without knowing they have it, likely don’t know they have it because of the vaccine. Here are some actual resources about pertussis and how the vaccine can create subclinical cases and a silent reservoir for disease transmission.

They say that vaccines aren’t that effective at preventing disease.
But 3 million children’s lives are saved every year by vaccination, and 2 million die every year from vaccine-preventable illnesses.

These two links are actually the same. These numbers are estimates from the WHO, and when it comes to estimates like these, I have some serious doubts about their accuracy. I haven’t dug into this particular estimate yet, but let me provide an example of where my doubt comes from. The WHO has also claimed that the polio vaccine campaign has prevented approximately 350,000 cases of paralysis each year! Dr. Jacob Puliyel breaks down the issue with this claim quite well.

“WHO claims five million children have been saved from polio paralysis. It is instructive to see how this figure is arrived at. In 1988, there were 32,419 cases of paralytic poliomyelitis. The WHO arbitrarily raised this number ten-fold to 350,000 claiming incomplete reporting. In 2004 with the changed definition, only culture positive paralysis was considered polio and there were 2000 such cases. Subtracting 2000 from 350,000, the WHO calculated that 348,000 children were saved from paralysis that year.”

They say that “natural infection” is better than vaccination.
But they’re wrong.

This link goes to a page titled “Measles Parties”. I think the issue with this statement is the author’s misunderstanding of what is meant by natural infection being better than vaccination. What is meant by this statement is that natural infection provides stronger longer lasting immunity than does protection from a vaccine. Let me just quote this statement from Dr. Paul Offit, who is one of the sources in some of the next links:

“Furthermore, although Sears is correct in stating that natural immunity is generally better than vaccine-induced immunity, the high price of natural immunity, that is, occasionally severe and fatal disease, is a risk not worth taking.”

I disagree with the second half of that statement, but this blog author’s own sources recognize that natural immunity is better than vaccine-induced immunity.

They say that vaccines haven’t been rigorously tested for safety.
But vaccines are subjected to a higher level of scrutiny than any other medicine. For example, this study tested the safety and effectiveness of the pneumococcal vaccine in more than 37,868 children.

The first link is to a critique of Dr. Bob Sears’ book by Dr. Paul Offit. And the second link didn’t work for me, but I’m assuming she means this study.

Now I personally have a hard time believing that a man who holds a research position sponsored by Merck, has a patent for the vaccine Rotateq from which he has received an unspecified amount in royalties has un unbiased opinion on this topic. Dr. Offit has made same dubious statements in the past, such as babies can tolerate 10,000 vaccines at once. But like I said before with the previous link to an article criticizing Dr. Sears, it seems that if you don’t follow the CDC schedule exactly, then you are anti-vaccine.

Concerning the safety and effectiveness study for the pneumococcal vaccine and pretty much all vaccine safety studies, the problem that I and most others who question vaccine safety is not the number of children in the study. The problem is the lack of use of a proper placebo. In this study, the participants received “either the pneumococcal conjugate vaccine or meningococcus type C CRM197 conjugate.” Rather than comparing the vaccine to a saline solution, it is compared to another vaccine that is also designed to elicit immune responses. All this does is muddy the water when it comes to safety. Yet this is what passes as good science for vaccines. If this doesn’t strike you as insane, then I don’t know what else to tell you.

They will say that doctors won’t admit there are any side effects to vaccines.
But the side effects are well known, and except in very rare cases quite mild.

Actually some doctors won’t admit there are side effects to vaccines. I’ve heard countless stories from people where the doctor completely dismisses any concerns from the parent. Some side effects are known, but as previously stated, the safety studies don’t lend much clarity to the topic, and most studies only last a few weeks at most. There are very few studies looking at long-term side-effects from vaccines, and any that are out there are usually dismissed by claiming any association is just a coincidence. Here’s a further breakdown of vaccine side-effects and underreporting.

They say that the MMR vaccine causes autism.
It doesn’t. (The question of whether vaccines cause autism has been investigated in study after study, and they all show overwhelming evidence that they don’t.)

They say that thimerosal in vaccines causes autism.
It doesn’t, and it hasn’t been in most vaccines since 2001 anyway.

This vaccine-autism issue would take me entirely too long to go through in this post, so I’ll probably save it for another one. There are definite issues with each of the studies presented. I think it’s funny how they cite studies that say mmr doesn’t cause autism, and thimerosal doesn’t cause autism, therefore vaccines don’t cause autism. There are also other things in a vaccine which may be of concern neurologically. But I’ll touch on some of those issues later.

They say that the aluminum in vaccines (an adjuvant, or component of the vaccine designed to enhance the body’s immune response) is harmful to children.
But children consume more aluminum in natural breast milk than they do in vaccines, and far higher levels of aluminum are needed to cause harm.

This argument never ceases to amaze me. I can drink a can of Pepsi every day with no immediate health effects, but that doesn’t mean I want to inject it in my arm. The mode of delivery makes a huge difference here. The GI tract is designed to filter out undesirable things, and not absorb them into the body. Comparing an injection into the intramuscular or subcutaneous layer to ingesting food is a false analogy.

Aluminum is a known neurotoxin.

The safety studies for aluminum are sadly lacking. The medical consensus seems to be that we’ve been using them in vaccines for years, so they must be safe. If this sort of reasoning satisfies you, then go ahead and vaccinate. It’s a pretty poor rationale in my mind.

The safe level for aluminum in IV parenteral fluid has been set by the FDA at 4-5 mcg per kg of body weight per day. That means that a healthy newborn baby that weighs 8 lbs 12 ounces should be able to handle 20 mcg of aluminum. Why then does the Hepatitis B vaccine, which is typically given within 12 hours of birth, contain 250 mcg? At two months of age, following the recommended schedule, depending on the vaccines given, a baby could get up to 1225 mcg of aluminum injected. Even if the baby was a healthy 15 lbs, the safe level is still less than 40 mcg per day. Now admittedly this safe level was set based on a study on premature babies with impaired kidney function, so it’s possible that most children could clear more than the recommended safe level. But 10 times the safe level on the first day of life? And over 30 times the safe level in the second month? This is another issue with the mass vaccination program. It has no consideration for individual variation amongst children, one size fits all. What sort of damage might we be doing to kids with undetected impairment in their kidney function?

They say that the Vaccine Adverse Events Reporting System (and/or the “vaccine court”) proves that vaccines are harmful.
It doesn’t.

I agree it doesn’t. Of course it goes both ways, if we can’t use the vaccine court to show that vaccines are harmful, then it also can’t be used to exonerate vaccines. As for VAERS, there are several issues with it, and I won’t go into much detail here, but one of the issues is that of underreporting. The FDA has said that with a passive surveillance system such as VAERS, it is possible that less than 1% of adverse reactions may be reported.

I personally think that VAERS is pretty worthless when it comes to determining safety data for vaccines. At best, it may serve as an alert to health officials about possible issues, such as the increased risk of intussusception with one of the rotavirus vaccines, but due to the vast underreporting, this function is pretty limited.

They say that the normal vaccine schedule is too difficult for a child’s immune system to cope with.
It isn’t.

Seriously, more links to articles criticizing Dr. Sears? And the second one is the one already linked to multiple times. I’m sorry, but that’s not exactly what I would call proof for the statement that the vaccine schedule isn’t too difficult for a child’s immune system. How about linking to a study comparing vaccinated to unvaccinated kids to prove your statement? Oh that’s right, you can’t.

They say that if other people’s children are vaccinated, there’s no need for their children to get vaccinated.

I would never say this, and I don’t think that most people who choose not to vaccinate say this either. This seems like a pro-vaccine claim that people who don’t vaccinate are ‘hiding in the herd’. The vaccination status of other children has not affected my decision to vaccinate.

This is one of the most despicable arguments I’ve ever heard. First of all, vaccines aren’t always 100% effective, so it is possible for a vaccinated child to still become infected if exposed to a disease. Worse, there are some people who can’t receive vaccinations, because they are immune deficient, or because they are allergic to some component. Those people depend upon herd immunity to protect them. People who choose not to vaccinate their children against infectious diseases are putting not only their own children at risk, but also other people’s children.

So here’s the old herd immunity argument, which isn’t valid for all vaccines, so at best she could use this for only certain vaccines. I would say measles would probably be the best one for a herd immunity argument. Again, here’s a great look at the herd immunity argument in regards to measles by a PhD in Immunology, which I have previously linked to.

They say that ‘natural’, ‘alternative’ remedies are better than science-based medicine.
They aren’t.

I love how she frames that sentence, basically saying that natural and alternative remedies can’t be science-based.

The truth is that vaccines are one of our greatest public health achievements, and one of the most important things you can do to protect your child.

According to the same CDC page she links to, infant health is also a great public health achievement, and yet were does the US rank for rates of infant mortality amongst other industrialized countries? Dead last.

I can predict exactly the sort of response I will be getting from the anti-vaccine activists. Because they can’t argue effectively against the overwhelming scientific evidence about vaccines, they will say that I work for Big Pharma. (I don’t and never have). They will say that I’m not a scientist (I am), and that I’m an “Agent 666” (I don’t know what that is, but I’m pretty sure that I’m not one).

Welcome to the internet, where all the crazies like to come out and comment on things.

None of these things are true, but they are the reflexive response by the anti-vaccine activists because they have no facts to back up their position. On some level, deep down, they must understand this, and are afraid of the implications, so they attack the messenger.

Yes I’m quite sure that the only anti-vaccine people who comment on her blog posts are the crazy ones. Either that or she wants to frame it that way, because obviously anybody who disagrees with her is crazy.

Why are they lying to you? Some are doing it for profit, trying to sell their alternative remedies by making you afraid of science-based medicine. I’m sure that many others within the anti-vaccine movement have genuinely good intentions, and do honestly believe that vaccines are harmful. But as a certain astrophysicist recently said “The good thing about science is that it’s true whether or not you believe in it”. In the case of vaccine truthers, this is not a good thing. Good intentions will not prevent microbes from infecting and harming people, and the message that vaccines are dangerous is having dire consequences. There are outbreaks of vaccine-preventable illnesses now throughout the United States because of unvaccinated children.

The links in this paragraph don’t even deserve a response. Linking to other blogs and opinion pieces that rehash the same pro-vaccine propaganda doesn’t do anything to bolster your argument. You want to talk about profit motive? Look at how much pharmaceutical companies stand to make from the vaccine business. It’s the perfect business model. You get grants from the government to develop your product, you are immune to litigation for any harm your product might cause, you have a consumer market mandated for you, ensuring that there will always be demand for your product which means you don’t have to spend anything on marketing. From a business perspective, it sounds amazing.

“The good thing about science is that it’s true whether or not you believe it” seems to be the new quote going around to ‘crush’ the opposing view. The thing is, without context, it’s a pretty inane statement. What is science? Are you talking about the process of observation and experimentation? If so, then science is a tool used by flawed individuals who carry with them certain biases that can affect their interpretation of the data. Or does science refer to a specific branch of knowledge? If that’s the case, then this statement is easily rebutted by pointing out that previous ‘scientific fact’ has been proven wrong. There are certain fields of science that are subject to scientific laws (gravity, thermodynamics, etc.) which make it easier to come to a single consensus about the data. However, other fields do not have these underlying laws, and are therefore more apt to have varying interpretations of the same data. Think about the difference between Mathematics and Anthropology.

As for the statement that the outbreaks in the US are because of unvaccinated children, I refer you to the above article I linked to about measles and herd immunity.

In only one respect is my message the same as the anti-vaccine activists: Educate yourself. But while they mean “Read all these websites that support our position”, I suggest you should learn what the scientific community says. Learn how the immune system works. Go read about the history of disease before vaccines, and talk to older people who grew up when polio, measles, and other diseases couldn’t be prevented. Go read about how vaccines are developed, and how they work. Read about Andrew Wakefield, and how his paper that claimed a link between the MMR vaccine and autism has been withdrawn, and his medical license has been revoked. Read the numerous, huge studies that have explicitly examined whether autism is caused by the vaccine…and found nothing. (While you’re at it, read about the ongoing research to determine what IS the cause—or causes —of autism, which is not helped by people continuing to insist that vaccines cause it).

“While they say ‘Read all these websites that support our position.’” Isn’t this exactly what she just did? Her links are all to websites that support her position. Not once did she respond to any evidence from the other side, instead she tries to paint ‘anti-vaxxers’ as crazy people who resort to name calling because they have no facts to back up what they say.

That may seem like a lot of work, and scientific papers can seem intimidating to read. But reading scientific articles is a skill that can be mastered. Here’s a great resource for evaluating medical information on the internet, and I wrote a guide for non-scientists on how to read and understand the scientific literature. You owe it to your children, and to yourself, to thoroughly investigate the issue. Don’t rely on what some stranger on the internet says (not even me!). Read the scientific studies that I linked to in this post for yourself, and talk to your pediatricians. Despite what the anti-vaccine community is telling you, you don’t need to be afraid of the vaccines. You should instead be afraid of what happens without them.

Most links were not to scientific studies but rather to other peoples’ blogs, or opinion pieces on the subject matter. Most sites had few if any references. That’s a problem I have with websites like the CDC or the WHO. They rarely cite where their information comes from, so at that point it becomes an appeal to authority. This blog post claims that the other side is promoting fear of vaccines, yet she blatantly promotes fear of not vaccinating, and I just don’t like articles that promote hysteria.

I will eventually go through and address the statements about autism and the like, but for now, this post is long enough.