American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, January 20, 2016

No vaccination, no camp. Finally

In 2013, Emily Stillman developed a headache. Within hours she was dead. Emily died from one of the dozens of diseases that medical science has managed to control through vaccination. Unfortunately, she had not been vaccinated against the type of meningitis that took her. Despite the existence of a safe and effective vaccine, type B meningococcal meningitis was not seen as enough of a threat for mass vaccination in the U.S.

Thanks to efforts led by her mother Alicia, the meningitis B vaccine is now available in the U.S. to protect our children from Emily's fate.

Vaccination is a type of immunotherapy. For over 100 years, people have had their immune systems trained to defend against diseases that in the past caused great suffering and millions upon millions of deaths.

The concept is fairly simple: expose a person's immune system to an important part of a germ, and the immune system develops a “memory” for the germ. When you encounter, say, measles after having been vaccinated, your immune system's memory cells start to divide quickly and crank out antibodies to defend against the disease.

Smallpox was the first global killer eliminated completely as a human disease. Polio is getting close. All of this is due to exceptional public health efforts centered around vaccination.

There has been a seemingly-bizarre backlash against vaccination over the last decade led by people living mostly in affluent communities. There are a ton of great books on this phenomenon, especially Seth Mnookin's The Panic Virus, and Paul Offit's Deadly Choices.

Leaving aside the details, about which much has been written, the medical and public health communities are unanimous in support of childhood vaccination. Of course there are always individual doctors who go against what science has shown us. One of them lives and practices near me.

Dr. David Brownstein is a family doctor whose “goal is to inform the world about the power of holistic health solutions,” whatever that might mean. Yesterday he posted a dangerous and poorly-informed piece on his website. First a bit of cultural background.

Dr. Brownstein practices in the heart of Michigan's Jewish community. Among American Jews, summer camping has been an important part of childhood for nearly a century. In the early part of the 20th century, it was felt that city children would benefit greatly from exposure to nature. Jews were not allowed to attend most camps and started their own. The tradition has remained strong.

I spend a week every summer helping to keep an eye on the kids at 1 such camp. During the flu epidemic of 2008–09, I watched as dozens of kids came down with a new flu strain, 1 for which a shot had not yet been developed. It was a frightening lesson in what can happen in unvaccinated populations. Thankfully, the strain wasn't deadly in this population. Among the hardest hit were pregnant women.

Still, it did put a damper on the summer for many kids. Last winter, another in which we had a flu strain not well-covered by the vaccine, I lost nearly half a dozen patients. All were elderly, and really didn't stand much of a chance. But if the people around them had been immune they might have lived through the winter never knowing what might have happened.

My daughter, who attends the same camp as I did, has had every shot, always on schedule. Thankfully so have her friends. I'd be very hesitant to let her play with kids who weren't vaccinated, both because of the small but real risk she could catch something, and because I would not want her to give an illness to someone else.

One of our largest summer camps here reportedly sent out a letter this week informing the community that all staff and campers must be fully immunized to attend camp next summer. This is great news for our kids.

But Dr. Brownstein doesn't think so. His blog lists the usual arguments against requiring vaccination, all of which are, to be blunt, total bullshit. It's not even good bullshit, but bullshit that has long been known to be, well, bullshit.

For those of you who want the detail, read on. If you don't, feel free to skip to the final paragraph for a summary. So let's go through Brownstein's arguments point-by-point:

“You might assume that Tamarack Camps, which has been around for over 100 years, must have had an outbreak of a communicable disease. However, if that is true, I missed it. In fact, I would be interested in any data from Tamarack Camps of any outbreak of a communicable disease in its 100-year history.”

I call this the “seat belt” argument. I've never been in a serious crash, but studies clearly show that if I were, wearing a seat belt could make the difference between life and death. The same is true for vaccination. While we may not see a lot of tetanus in this country, we still need to protect ourselves. Tetanus is a particularly hideous death, and we see so little precisely because of our vaccination efforts.

“Perhaps Camp Tamarack is unaware that over $3 billion has been awarded by the Federal Government to children and adults injured by vaccines. Maybe Camp Tamarack can assure all who will have to be fully vaccinated to attend camp that it is safe to inject numerous doses of neurotoxins like mercury, aluminum and formaldehyde into any living being. As far as I am aware, there are zero — ZERO — safety studies on injecting a neurotoxin into a living being. I would like to see where Jewish law says it is safe to inject a neurotoxin into a baby or any living being.”

This is completely wrong in every conceivable way. First, the “$3 billion” thing: vaccines are not very profitable, and people who listen to Brownstein might be tempted to sue a drug company after getting a vaccine and having something bad happen. Serious vaccination reactions are vanishingly rare, but in order to protect the public and to protect the companies that make vaccines, the government has set up a “vaccine court.” While you may sue a drug company for causing injury through a poorly manufactured vaccine, you cannot sue them simply because you think you had a reaction. This court liberally awards money to people who feel they have been injured by a vaccine. The level of evidence needed is minimal. It is meant as a safety net both for those who are truly injured and for those who think they are, even if they might not be able to prove it in a normal court.

The “toxin” gambit uses scary words out of their scientific context. Aluminum is used in some vaccines in order to help create a stronger immune reaction. This allows us to use less of the actual antigens derived from the germ. It is not present in amounts that cause harm. Formaldehyde is sometimes present in tiny amounts left over from the preservation process. Your own body manufactures more formaldehyde in a day during its normal chemical processes than you would get from a lifetime of vaccines. The tiny amount that might be left in your shots is trivial for your body to deal with.

Mercury is not present in most vaccines. It is present in a few in the form of thimerosal, a preservative that keeps vaccinations from becoming contaminated. Thimerosal in vaccines has been found in study after study to be harmless. No “neurotoxins” are injected into our children as part of the vaccination process. That is either a lie or profound ignorance of biology. Tetanus, on the other hand, produces a potent neurotoxin that kills people in a uniquely painful way.

“Maybe Camp Tamarack should take notice that there is a whistle blower at the CDC — a senior scientist who authored research papers on childhood vaccinations — who has stated that the CDC has hidden and altered data that confirmed a link with the MMR vaccine to autism. Or, perhaps they could provide an explanation of why another whistleblower scientist who worked at Merck (who manufactures the MMR vaccine) has filed a federal lawsuit saying the mumps data used to justify the MMR vaccine was falsified by Merck.”

This bears repeating: There is no link between MMR vaccines and autism. None. The “link” was from a fraudulent paper published in a British medical journal by Dr. Andrew Wakefield. The paper has been retracted and his license has been revoked due to his fraud.

Dr. Brownstein goes on to make an argument that would be funny if it weren't so dangerous. He argues that as vaccination rates have risen, so have childhood disabilities. Any 7th grade forensics student could tell you what the problem is here: just because 2 things occur at the same time does not mean 1 is the cause of the other.

For example, in the same time period cited by Brownstein, lead exposure in kids decreased dramatically, mostly due to the elimination of leaded gasoline. So was lead exposure protecting our kids from learning disabilities and autism? (For the definitive, ground-breaking book on the “rise” of autism, see Steve Silberman's Neurotribes.)

Maybe you skipped the details above and have arrived down here to the bottom of the page. Here's the short version.

Vaccination, along with water sanitation, has saved billions of lives. Most of us are too young to remember life before vaccines, but before the fifties, being a parent was terrifying. Vaccination has been shown over and over to be safe and effective, so much so that there is nothing that unites the medical community more strongly. Failing to vaccinate your child puts them at risk, and puts others' kids at risk.

Summer camps are intimate environments, with kids sharing space, clothes, water bottles. I've seen what an outbreak of a mild disease can do. Can you imagine what would happen if, say, meningitis broke out at a camp? You don't have to imagine it, all you have to do is read history.

Camp Tamarack should be lauded for their policy of full vaccination. If there is a kid who for some medical reason can't get all their vaccines, this policy will protect them from unvaccinated cabin-mates. And there is no downside to the policy.

Dr. Brownstein is wrong on the facts. That's not my opinion. What is my opinion is that doctors like him are a threat to public health. Doctors who spread incorrect information about health and disease are endangering my child and yours. They are a threat to public health. It is my personal belief that doctors who practice so strongly against the standard of care should lose their license to practice.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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