More on Vaccination: A Simple Risk-Benefit Analysis Regarding the Measles Vaccine

The other day, I took my perfectly healthy, 18-month-old son to the doctor. The nurse weighed him and measured his height (27lbs., 4oz., and 33.25"). The doctor looked in his eyes, nose, mouth, and ears, felt his abdomen, listened to his heart and lungs, asked some questions about his development. Then the nurse came back, and I held him still for a minute while the nurse swabbed his bare thigh with some alcohol and jabbed him with a needle. My son cried indignantly. I put his pants on, thanked the nurse and doctor, declined to make a further appointment at the moment (his next checkup will be when he turns two), and left the office. I buckled him and his brother into their car seats (checking to make sure their straps were properly tightened and their chest clips were aligned with their arm pits), then drove them to the park, where they played for an hour with a babysitter while I went to appointment of my own. It was a sunny, gorgeous, perfect day, and the boys had fun going down the slides, swinging, and eating a snack. I picked them up, buckled them carefully into their car seats again, and drove to McDonald's, where they ate a special lunch. Then we got back in the car and drove home, following traffic laws. I nursed the toddler in his bed, and he fell asleep and took a nap while his brother watched TV. The rest of the day was similarly uneventful.

The next day while getting the toddler dressed, I checked his thigh where he had been given the shot and couldn't find the spot where the needle went in.

Today, he is cheerfully playing with his brother in the living room. We're going to the supermarket soon. Later, we'll go see the oldest in the school talent show and have tacos for dinner.

If you're waiting for some kind of dramatic, "AND THEN," you're not going to get one. And that's the point.

I have "come out," as it were, as pro-vaccination. I believe that vaccinations are one of the greatest medical advancements and discoveries of the past several centuries. I have seen the data and charts and listened to the expert researchers. I have read articles by people who believe vaccinations are in some way harmful and do not find their arguments to be convincing. All four of my children are and will continue to be vaccinated according to the schedule recommended by the CDC and their pediatrician. The only vaccination I refuse is the hepatitis B shot at birth, because I have done my research and learned that the purpose of the newborn hep B vaccination is to prevent vertical transmission of hepatitis B from the mother. Since I know I do not have hepatitis B, I feel it is unnecessary to give this vaccination immediately upon being born. My concern is that so much happens in the first day or two postpartum that I want to do as little as possible to disrupt my new baby's simple needs to be near me and breastfeed, while still taking the recommended courses of action when medically appropriate. Thus, my children begin the hep B series at their two-month checkup, along with several other shots.

You only hear stories about people who have a story to tell. When their day is as completely ordinary as mine was, it's not interesting. And since most of the millions of children who receive vaccines each year have completely ordinary days afterward, we don't hear their stories. See, it's easy to use scare tactics to drum up public outrage and support for your cause. And when you've personally witnessed a child who had a bad reaction to a vaccination, it's completely understandable that you would be scared that something like that could happen to your own child. I get that.

The problem is, what I encounter again and again when I see anti-vaccination rhetoric is a complete misunderstanding of statistics and how they work.

For example, someone might say: "Measles was on the decline before the vaccine was introduced." But that is not a correct interpretation of the statistics. Measles deaths were on the decline, due to better sanitation and medical care, but measles cases were still quite frequent, and so were complications of measles. According to the CDC: "In the decade before 1963 when a vaccine became available, nearly all children got measles by the time they were 15 years of age. It is estimated 3 to 4 million people in the United States were infected each year. Also each year an estimated 400 to 500 people died, 48,000 were hospitalized, and 4,000 suffered encephalitis (swelling of the brain) from measles" [my emphasis]. However, "Widespread use of measles vaccine has led to a greater than 99% reduction in measles cases in the United States compared with the pre-vaccine era."

Another misuse or misunderstanding of statistical information I see frequently is the assertion that while measles has caused no (or less than a handful) of deaths in the past 15 years, the measles vaccine has caused over 100. This represents a clear misunderstanding of how statistics and risk-benefit assessments work. Consider the number of measles cases there were in 15 years, and divide the number of deaths by that relatively small number. Your result is the risk of dying from measles in this century. The number of measles cases in the United States in 2014 was almost 600, and so far in 2015 is close to 200. So let's say there were 800 measles cases in the last year and a half (in the United States - there are millions of cases of measles yearly in other parts of the world and tens of thousands die from it). As far as I can tell there have been no deaths from measles in that same period - in the United States - or perhaps one. A toddler did die of measles in Germany recently (also a First World country with good sanitation and health care). If we say one death out of 800 cases of measles, we get a risk of 1/800 = 0.00125 or about 0.1% (which was also the risk of death from measles before the vaccine was introduced). Indeed, according to studies, the general risk of dying from measles is about 0.1 to 0.2%, or 1 to 2 out of 1000. Now, the only reasonable comparison to make with this is the risk of death from the measles vaccine. To find out the risk of dying from a measles vaccine, we need to know how many measles vaccines were administered in 2014 and how many died from receiving that vaccine, and do the same math. That number is harder to come by, but we can estimate. There are close to 4 million babies born in the United States each year. About 98% of these babies will receive an MMR vaccine at age 12 - 15 months. 98% of 4 millon = 3,920,000 (3.9 million). I can't find data on how many deaths are attributed to the measles vaccine in a given year, but for the sake of argument, let's take the CDC's report that there were possibly 3 deaths from encephalitis that apparently was caused by the MMR vaccine. (If I'm reading this correctly, that's three deaths ever, not three deaths per year, so I may be considerably overestimating this number. But, for the sake of argument, let's use it anyway.) So if three infants die because of receiving the MMR vaccine, out of 3.9 million who received it, that's a risk of death of approximately 0.000001, or 0.0001%. That's much smaller than the risk of dying from measles itself. If people stop vaccinating because they believe that the vaccine is more dangerous than the disease, then we will begin seeing deaths in the hundreds again, once mass outbreaks start occurring with the regularity they did in the 1950s and 1960s.

Of course, measles deaths aren't the only concerns. There are plenty of other complications possible from measles, not the least of which is that your child will have to stay out of school for a week or two, as will all of your other children as they almost inevitably come down with measles as well. This is an economic risk more than a health risk, but it's worth considering!

Now, I understand that if your baby was one of those three that died of MMR-related encephalitis, it is no laughing matter, and knowing the stats is no comfort. But sometimes, even if we do a proper risk-benefit analysis, and we make the obviously safer choice, we might still fall into the unfortunate, tiny percentage. That's true in many areas of life.

Here's a good example of how that kind of thinking works: Let's talk about seat belts. You won't find many people who would say that you're safer if you don't wear a seat belt, right? I mean, really, almost everyone agrees that you should wear a seat belt when you're in the car and that seat belts save thousands of lives every year. Most states have laws requiring some or all of a car's occupants to wear a seat belt when the car is in motion. Very, very rarely, we hear of a case in which a person's life was saved by the fact that they were not wearing a seat belt. Perhaps the car hit a guard rail and then went into a river, and if the driver had been wearing their seat belt, they would have gone into the water, but because they were ejected from the car on the first impact, they didn't drown. Most reasonable people would agree that there is a minuscule chance of being saved by not wearing a seat belt, and this is not a reason to quit wearing your seat belt regularly. There are far, far, far more cases in which people are saved because they were properly restrained, or, tragically, they died because they were not wearing their seat belt.

If you knew that one-in-a-billion person who was saved by not wearing a seat belt, you might be inclined to think that seat belts aren't as safe as the "experts" say they are, that wearing a seat belt is actually dangerous because it can cause bruising, or that wearing your seat belt means you'll be trapped in the car after a bad crash. You might be inclined to think that because your friend survived by not wearing a seat belt, this might happen to other people, too, and you wouldn't want to be the one who keeps wearing a seat belt and put yourself in danger of dying in a similar situation to the one your friend survived.

That all sounds ludicrous, right? The same type of arguments are made with regard to vaccines. Yes, unfortunately, tragically, some children suffer adverse effects from vaccines. A very, very small percentage of babies and children have experienced severe side effects related to receiving a vaccine. (Note: Study after study has failed to identify any risk of autism from vaccines. But other vaccine injuries do occur and are noted by the CDC on their website as possible complications.) I don't take this lightly. Indeed, I think more research needs to be done to try to identify individuals who are at risk of complications so they can be protected.

A final thought on this for the day.

If my car is broken, I take it to a mechanic to fix it. I might do some quick research on the internet to find out what the likely problem is and how much I can expect to pay to fix it. I might even look to see if it's something I can try to fix myself. But it is often the case that I need someone who knows more about cars than I do to investigate the problem and fix it. Sure, I could spend weeks learning all there is to know about my Toyota, find a supplier for the parts I need, and have a go at it, but most likely I would not do as good a job as someone who is an expert in the field. I haven't seen hundreds of Toyotas with this problem. I haven't fixed it dozens of times. I don't know all the pitfalls and tricks and shortcuts that can make the task easier, more efficient, and safer. And I might end up doing more harm than good if there's actually something else going on.

People specialize in various fields and become experts in those fields. Most people cannot be experts in everything. When we need information or action regarding a field we are not as familiar with, we consult someone who lives and breathes that subject. If we don't like what they have to say, we find another expert and get another opinion from someone who also lives and breathes that subject. If I don't like the quote the first contractor gave me for replacing the floor in my kitchen, I'll call another one. I don't know how to lay flooring and I don't think I'd do a good job. If I don't like the landscape design the first gardener proposed for my front yard, I might call another gardener and get his thoughts. I don't know anything about gardening and design, or irrigation systems, or native plants, so I wouldn't trust myself to do a good job.

In a similar vein, I can do some reading on the internet about vaccines, how they work, risks and benefits, and so on, but I don't trust myself to be able to completely assimilate all of this information because I don't understand all of it. I haven't spent years studying biology, epidemiology, immunology, statistics, anatomy, physiology, and so on. The best I can do is some shallow research, learn what questions I'd like to ask, and then ask the people who have spent years studying those things, and who live and breathe this kind of work, to explain it to me as best they can. And when those experts recommend a course of action - and not just one of them, but something close to all of them - then it makes sense to me to follow that advice.

This is also my stance when it comes to other aspects of life. For example, overwhelming evidence from decades of research has concluded that breastmilk is the optimal nutrition for babies and that breastfeeding results in healthier babies and a healthier population. Thus, I advocate for breastfeeding, breastfeeding education, and breastfeeding support.

When there is more ambiguity in the research results, such as those that report on various types and effects of diet and exercise, then I read what I can and make a decision I feel comfortable with based on what we know so far. I may also consult people whose opinions I trust for what they recommend or understand about the subject.

I understand enough about statistics to look at the statistics I'm given even by people who are against vaccination and make an informed risk-benefit analysis. I am comfortable - very comfortable - with my decision to administer vaccines to my children and to have appropriate ones administered to me as well. And, from the standpoint of public health, I understand enough about how disease spreads to know that it's important for as many people as possible to receive those vaccinations.

Vaccines Keep Our Kids Safe

The measles outbreak traced to Disneyland this winter has created a great resurgence in the "vaccinate or do not vaccinate" debates that surface relatively often in parenting discussions. The media has been covering different angles, from encouraging everyone to get their shots to heart-rending stories of children purportedly injured by a vaccine. It's a hot topic.

I did an Ask-Me Monday video on vaccines a couple of months ago, coincidentally just before the Disneyland outbreak. (See it here.) Predictably, people who are against vaccines sought out my video so that they could pick a fight. I chose to engage calmly, state my opinions, and be done with it. I know that throwing facts at people doesn't change their minds. Indeed, there have been studies on this very topic, and the more you argue, the more people dig in their heels.

The vibe I get from parents who are genuinely concerned and thoughtfully considering whether they should consent to having their children vaccinated - as opposed to being solidly in the "anti-vaxxer" camp - is that they are trying to keep their children safe. They hear stories of children who suffered brain damage, organ damage, or death from a rare reaction or complication of receiving a vaccine. They don't want to take the risk for their own children. The word "autism" gets tossed around. We see link after link to blog posts and opinion pieces about how we're all being duped by the pharmaceutical companies, how there's a great conspiracy in the FDA and the CDC to force all of us to be injected with poison, and how a child was perfectly healthy and typical before they got the DTaP or the MMR shot, and afterward showed signs of brain damage or a blood disorder or had uncontrollable seizures.

Well, obviously we don't want to become involved with or duped by government conspiracies! And don't you know that there's formaldehyde in those shots?!

What no one bothers to say when making these arguments is that there's another side. There's the parents whose newborn babies were exposed to measles or whooping cough because of an unvaccinated child in their community. There are the children who contract these diseases and become severely ill and spend weeks or months in the hospital. There are the babies who die a slow, horrible death wracked by rib-cracking coughs until they turn blue from lack of oxygen and suffocate in their own mucus. There are the children left paralyzed by polio or suffer encephalitis from measles. There are the women who lose pregnancies because of rubella infection.

Underneath all the sob stories and "what if's" are parents who are just trying to figure out what is best for their own children. How do we protect our kids and our families? What should we be afraid of? What are the real risks?

I'm going to take this discussion outside of vaccines to look at a bigger picture. There is risk in everything we do every day. Indeed, one of the riskiest things we do every day with ourselves and our children is drive our cars. Did you know that car accidents are one of the leading causes of death and injury for children? Car accidents. But I bet most of you put your kids in the car almost daily. I know I do. School and daycare drop-offs and pickups, shopping, errands, visiting friends, grabbing a bite to eat, playdates, road trips, vacations, all sorts of reasons to get in the car.

And do you, each and every time you get in the car, double check that your kids are in appropriate child restraints, installed and buckled correctly? Do you take your car in for regular maintenance? Are your brakes and tires in good repair? Do you have a hands-free device for your cell phone, or do you put your cell phone away while you drive so as to avoid distractions? Do you glance in your mirrors and check your blind spot every time you change lanes?

So, what if we decide the risk of driving is too high and we stay home? There's a risk of earthquakes or windstorms. In the winter, ice could bring a tree branch down on your house. If you live in tornado country, you could end up trapped under the rubble of your home. If you live in the hurricane zone, another Katrina could turn your life upside down. You could forget about the pot of soup on the stove and set your house on fire. You could slip in the bathroom and hit your head on the toilet and knock yourself out.

Things can happen anywhere. And we can't live our lives in fear. It's impossible to account for every possible scenario. It's impossible to be completely, 100% safe, all the time.

So, we do the best we can with the information we have. We weigh the risks and benefits as we understand them. And if doing something has risk and not doing something also has risk, it is very hard to choose. But if the goal is to keep our kids as safe as possible, it's important to do what we can to minimize risk in all situations. Like buckling them correctly in a properly installed, appropriate car seat when on the road, and having them wear a helmet when they ride a bike, and putting a fence around the pool.

When it comes to medical procedures, and vaccines specifically, certainly, it is much easier not to do something. The passive route feels less risky. If I don't give my baby this injection, then it can't hurt him!

It's important, then to consider the other half of the equation. If you don't give your child this injection and he contracts measles, say, through contact with a tourist at Disneyland, then measles can hurt him. And not just him. Measles can affect him, and his siblings, and his cousins, and his friends, and his friends' families, and their friends, and at some point, someone will die. Maybe it won't be your kid. Maybe your kid will miss two weeks of school and recover and that's the end of it, and you'll be relieved that everything is fine. But maybe some other baby down the line of contagion isn't so lucky.

And if you do give your child that injection, and you go to Disneyland and come in contact with a tourist who is carrying measles, and your child doesn't get measles, well, then clearly you made the right choice in getting that shot!

It's not simple. And yet, it is. Because if we look at the research, at the documented risks, at the statistics, it becomes clear that the risk of contracting a disease, and the risks of complications from that disease, are higher than the risks associated with the vaccine. If we look past the sob stories and the fear-mongering and the impassioned pleas, if we look at the cold, hard facts, at the science, it's purely, radically simple.

Vaccinations work.

Protect your children and all of the people your children come in contact with every day.

Get vaccinated.

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Statistics:

Complications of measles:
http://www.cdc.gov/vaccines/pubs/pinkbook/meas.html#complications
Note: 30% of measles cases experience some complication, such as diarrhea, ear infection, or pneumonia. Pneumonia is the leading cause of death from complications of measles. The risk of death from measles is 0.2%, or 2 in 1000.

Adverse reactions to MMR Vaccine:
http://www.cdc.gov/vaccines/pubs/pinkbook/meas.html#adverse
Note: 5 to 15% of susceptible persons may develop a high fever but be otherwise asymptomatic. As for serious complications, 1 in 30,000 may develop thrombocytopenia (a blood disorder in which blood does not clot), but the risk of thrombocytopenia due to measles infection is much higher than the risk of thrombocytopenia due to the measles vaccine. Other risks are so rare as to almost be incalculable.

Yes, it is possible to have an adverse reaction to a vaccine. It's important to acknowledge that. But it is far, far more likely to have complications from the disease itself.

Why I Vaccinate My Children

My youngest, Baby Y, had his four-month well-baby checkup today. He weighed in at a healthy 18 pounds even and was a robust 26.75 inches long. At four months, he is rivaling his three brothers for size and chunkiness. Four months also meant a second round of vaccinations for my little one. He needed rotavirus, which is administered orally, as well as shots for hepatitis B, Hib, pneumococcal, diphtheria, pertussis, tetanus, and polio (some were combined, so it was three shots total). He didn't even react when the first shot was given, and cried briefly after the third. He slept for a few hours and is now playing happily, like nothing happened.

Of course, something did happen. Something extraordinary, really, if you think about it. A hundred years ago, diseases like polio ravaged young children, killing or paralyzing many. Diphtheria was a real threat, as was pertussis (whooping cough). While whooping cough isn't terribly dangerous today to those with developed immune systems, it can be, and often is, fatal for young babies. Vaccinations are one of the greatest medical advances of our time, along with antibiotics, improving length and quality of life and preventing much childhood suffering.

My husband and I choose to vaccinate our children according to the CDC schedule. We believe that it is not only our responsibility to our own children but to society at large to aid in limiting the spread of preventable diseases. My children are growing up in a world where they don't have to worry about losing a sibling to polio or a friend to pneumococcal disease or meningitis, and they are growing up in such a world because of the miracle of vaccinations. We can and will do our part to protect our own children and those they come in contact with.

We are not sheep blindly following our doctors' recommendations and the "guv'mint's" instructions. We are aware of the arguments against vaccinations and for delaying them. We are also aware of the science behind vaccinations, how they work, and that there are risks that come with giving vaccinations. We believe that the benefits of vaccination far outweigh the risks and that the risks posed by the diseases prevented by vaccines far outweigh the risks posed by the vaccines themselves.

Because my children have shown no adverse reaction to being vaccinated, I am very comfortable continuing to have them receive immunizations on schedule at their regular physicals. The only shot I refuse is the hepatitis B shot at birth. Its purpose is to prevent vertical transmission of hep B from mother to baby, and since I do not have hepatitis B (and, indeed, was vaccinated for it and received a booster series as a teenager), I feel it is unnecessary to add anything to a newborn's already busy first few weeks of life. The hep B schedule, then, starts at two months for my kids instead of birth. I also will put off a vaccination for a few weeks if my child is sick, because I want to be sure of the source of any symptoms. This is all per the recommendations of my doctor and the CDC.

Some children do have adverse reactions to vaccines, and in some cases these reactions are life-changing or even fatal. I know that. Any time we add something that nature didn't put there, we assume risk. Any medical procedure we undertake, any medication we take, any surgery we opt for puts us at risk that doesn't exist without that action. But we also assume risk when we do not avail ourselves of the advantages afforded us by modern medicine. Many of these diseases we vaccinate against carry a risk of suffering and even death. These are not trivial diseases. Polio is not like a minor cold. Pertussis is not a little cough. It is unacceptable, to me, to expose my children to these greater risks of disease, suffering, and possibly life-altering complications when the alternative is a little shot a few times as a baby, and possibly a booster when they're older, even given the possible risks and side effects of the vaccines themselves.

Vaccines generally work for the individual, but they work better when everyone gets them. If there is a measles outbreak in my town, for example, brought in by someone not vaccinated against measles, it puts my children at risk because the vaccine may not be 100% effective for them. However, their chances of being exposed to measles are considerably lower because the majority of people they come in contact with are also vaccinated. If one of my children were to be exposed to measles, it puts my young baby at risk because he is not old enough yet to receive the vaccine and could be infected with measles. The more people who are vaccinated against measles, the smaller the chance that anyone in my family will be exposed to it. And, vice versa, if my family members are vaccinated against measles, it reduces the chances that the people they come in contact with could be exposed to measles through them.

We protect each other by protecting ourselves.

Finally, there are definitely some individuals who cannot be vaccinated. Perhaps their immune systems are compromised. Perhaps they are allergic to an ingredient in the vaccine. Perhaps they have had a severe reaction in the past to an injection and cannot risk repeating that scenario. The rest of us being vaccinated also protects those individuals who cannot be vaccinated.

We've all seen how easily a cold or cough or stomach virus races through an office or classroom. Imagine if instead of fighting off cold-weather stuffy noses and the occasional 24-hour stomach bug, we were also constantly in fear of catching diphtheria or whooping cough.

Scary to contemplate, isn't it?

Protect your children. Protect my children. Protect the children who can't protect themselves. I vaccinate. Will you?