Silencing the Anti-vaccination Proponents - A Long Drawn Battle?
Vaccines have contributed to the eradication of smallpox, one of the most contagious and deadly diseases known to man. Any opinion to the contrary need to be evidence based. We have managed to eradicate Polio from our country by applying and experimenting upon the principle of herd immunity and tirelessly countering the negative propaganda by vested interests. Yet it is disheartening to note that diphtheria and measles are infiltrating into the immunological fortress we have built and children are falling easy prey to the cultural misunderstandings and antagonism to vaccination from various quarters.
Opposition to vaccination, from a wide array of vaccine critics, has existed since the earliest vaccination campaigns. Although the benefits of preventing suffering and death from serious infectious diseases greatly outweigh the risks of rare adverse effects, following immunisation, disputes have arisen over the morality, ethics, effectiveness and safety of vaccination. Opposition to vaccination is raised by vaccination critics pointing towards the ineffectiveness of vaccines and vaccine safety. Some religious groups hold an antagonistic stance on vaccination and some political groups oppose mandatory vaccination on the grounds of individual liberty. In response, concern has been raised that spreading unfounded information about the medical risks of vaccines increases rates of life-threatening infections, not only in the children whose parents refused vaccinations, but also in other children, perhaps too young for vaccines, who could contract infections from unvaccinated carriers. A more extreme response to this concern is the claim that spreading false information about vaccine risks amounts to involuntary manslaughter, claiming that celebrity promotion of the vaccine-autism link was followed by "an increase in the number of vaccine preventable illnesses as well as an increase in the number of vaccine preventable deaths" and thus "may be indirectly responsible for at least some of these illnesses and deaths” (WHO, ND)
Most infamous association quoted by the distractors is the link between autism and Thiomersal in Measles vaccine. A seminal study in Lancet (1998) by Andrew Wakefield having claimed to show a connection between the MMR vaccine and autism is their favourite pick. Resulting impact of the study peppered with media coverage was disastrous leading to a surge of preventable disease in Great Britain. However, several follow up studies conducted in different parts of the world by enthusiastic researchers to unravel the association if any about measles vaccine and autism disproved the original hypothesis about measles vaccine and autism.
Opponents to vaccination vociferously state that vaccine ingredients result in more harm than good. Most infamous association quoted by the distractors is the link between autism and Thiomersal in Measles vaccine. A seminal study in Lancet (1998) by Andrew Wakefield having claimed to show a connection between the MMR vaccine and autism is their favourite pick. Resulting impact of the study peppered with media coverage was disastrous leading to a surge of preventable disease in Great Britain. However several follow up studies conducted in different parts of the world by enthusiastic researchers to unravel the association if any about measles vaccine and autism disproved the original hypothesis about measles vaccine and autism. Vaccine protagonists heaved a sigh of relief following Institute of Medicine’s (Immunization Safety Review Committee) reports that the evidence was inadequate to either accept or reject a causal relationship between thimerosal exposure and the neurodevelopmental disorders. Following this report additional studies were carried out in several countries like USA, UK, Denmark, Sweden etc. The original claims have been criticised for being based on uncontrolled, anecdotal associations, and more recently, some of the study authors have retracted their interpretation associating MMR vaccines with autism. The final nail in the coffin to the thimerosal-vaccine-autism hypothesis is that five years after the removal of thimerosal (i.e. 2007), autism diagnosis rates have continued to increase (IDIC, 2007). In 2011, Flaherty, in his publication in the Annals of Pharmacotherapy aptly described the vaccine-autism connection as "the most damaging medical hoax of the last 100 years”. Accusations still exists that Polio vaccines are contaminated with Simian virus 40 which may cause tumours. Follow-up of a cohort of 1073 persons, unique because they received SV40-contaminated poliovirus vaccines as newborns in 1961–63, was done to test the hypothesis that this had caused tumours. After more than 35 years of follow-up, no overall excess of deaths from cancer in these individuals who as infants received poliovirus vaccines contaminated with SV40 was found. The polio vaccine currently used is no longer prepared in primary rhesus monkey kidney cells. It is produced in cultures containing monkey kidney cells and continuous cell lines (Vero or diploid cells) that have been extensively tested for contaminants, including SV40.
Health professionals need to come to truce with the reality that despite the growing scientific consensus that vaccines are safe a stubborn vocal minority claims otherwise, threatening the effectiveness of National immunisation programme. Yet, despite a long history of safety and effectiveness, vaccines have always had their critics: some parents and a tiny fringe of doctors question whether vaccinating children is worth what they perceive as the risks (Novella, 2013). In recent years, the anti-vaccination movement, largely based on poor science and fear-mongering, has become more vocal and even hostile (Hughes 2007). The World Health Organization states that “the two public health interventions that have had the greatest impact on the world’s health are clean water and vaccines”. Concern about vaccine safety is a potential barrier to immunisation; and reductions in vaccination rates have been described after media reporting of adverse effects. Vaccines contain constituents such as preservatives, stabilisers, adjuvants and biological growth media, which may contribute to consumer concern about vaccine safety; specifically: presence of preservatives; likelihood of allergic reactions; and constituents of human or animal origin. Community-based health professionals are in a key position to address these concerns by providing accurate information about vaccine constituents and components.
However, noted Muslim scholars are of the view that Shariah law includes the principle of “transformation”, where objects can be changed into another object with totally different properties and character, and this can turn unclean objects into clean and permissible objects. Within such a ruling, gelatin made from an unclean animal may be clean and permissible to ingest.
Religious and philosophical concerns regarding use of animal products needs to be addressed. Some religious groups who have dietary restrictions for certain animal products may be concerned about their presence in vaccines. Ingestion of pork products is forbidden in Islam and some Muslims may avoid medications that contain pork-derived products. However, noted Muslim scholars are of the view that Shariah law includes the principle of “transformation”, where objects can be changed into another object with totally different properties and character, and this can turn unclean objects into clean and permissible objects. Within such a ruling, gelatin made from an unclean animal may be clean and permissible to ingest (Wakefield et. al, 1998). Jews and Seventh-day Adventists also consider pork to be unclean. However, Jewish law permits use of porcine-derived products in non-edible forms such as parenteral formulations or binding agents in tablets. Similarly, pork-derived medical products are not prohibited for Seventh-day Adventists, although some individuals may prefer to avoid such products. Some strict vegetarians or vegans may also choose to avoid animal products in medications and vaccines; this is largely a personal choice and is likely to vary among individuals.
It is interesting to delve into case studies from Nigeria. Scholars of Kano in northern Nigeria issued a fatwa to the effect that it is not lawful to vaccinate their children against polio. According to them, the vaccine contains chemicals and hormones that may cause women to be infertile or impure elements that should not enter the body. In fact, the people of Kano followed the fatwa, and this resulted in the spread of polio among the children of the state. About 335 children were paralyzed by polio. Moreover, travellers have carried the poliovirus to eight other Muslim countries. Learned Islamic scholars from universities across the Muslim world denounced the fatwa claiming that Islam calls for adopting healthy methods and seeking medical treatment when needed, reiterating that, the field of medicine has received great care in Islamic civilization.
Re-emergence of Diphtheria in Malappuram district of Kerala is a noteworthy example of Orthodoxy defeating immunisation. Two locally powerful and orthodox groups have been traditionally leading a stiff resistance to immunisation. Easy targets of clerics and fringe elements are the lesser informed Muslims in the area, who are brainwashed into believing that vaccines are an instrument of the west being used to shrink the community (Murch et al, 2004).
Michael Fitzpatrick, author of MMR and Autism, raised his concerns regarding several anti-immunization websites posting inaccurate information about the evidence of a causal connection between vaccinations and autism. "Fitzpatrick's concern, however, is not just that misinformation is being spread on the Internet but that any parent who looks to the anti-immunization campaigns for information will readily find strident condemnations of the government, the medical establishment and the drug companies. Anybody who defends immunization can expect abuse and allegations of corruption or conspiracy. The basic thrust of much of it is that the pro-vaccination party has commercial links with drug companies. Fitzpatricks observation that perhaps not surprisingly, these anti-vaccination groups often have their own links with commercial interests needs to be explored .
Addressing the cultural, social and religious concerns on Vaccination fuelled by the anti vaccine lobby is a formidable challenge to a health professional. Every decision to undertake medical interventions involves a risk–benefit assessment. Vaccination decisions are made more emotive due to the influence of the anti-vaccination lobby.
A host of newer optional vaccines given to children in India, such as,recently introduced Rotavirus vaccine, Hib etc and many vaccines in pipeline are based on few studies most of which have been hospital based, which is a serious flaw. An objective researcher is often left in the dark on the true incidence rates of Rotavirus diarrhoea in our setting, which is important for understanding the differences in the epidemiology of childhood diarrhoea in the developed and developing countries. The current estimate of disease burden itself shows major gaps. Are the policy decisions on introducing series of optional vaccines taking into account various issues other than the safety and efficacy?
Against this background the skepticism regarding commercially driven vaccine industry may be true to certain extent. It is the professional duty of every doctor and the right of every parent to know the actual burden of prevalent diseases in one's own country and the mortality and morbidity afflicted by these diseases on one’s own child to aid rational decisions. Addressing the information gaps in disease epidemiology in our setting rather than accepting with blind faith the data provided by vaccine manufacturers in alliance with committees swearing national interests needs to be done urgently to silence the skeptics. “Stick on to your National Immunisation schedules” should be the mantra for prevention. However, doctors, health professionals and parents need to be prudent while using the ever expanding list of optional vaccines in the market since there seems to be a concerted effort to introduce needless vaccines by creating fear and paranoia among the masses against the background of improper scientific studies on the disease situation per se. Moreover, this creates a large socioeconomic divide in a society with individuals who can afford the vaccine and those who cannot, thus inadvertently creating an artificial immunity gap in disease causation and spread.
As the critics against vaccination have rightly pointed out, post marketing monitoring of adverse reactions should be done stringently. There is a recognition for the need for research on the true incidence of diseases like Chickenpox, Meningitis, Pneumococcal Pneumonia, Rotavirus diarrhea etc. in our country. We seem to rely totally on the figures of the West for introducing newer shots. Immunization programs depend on public confidence to be effective. Safety concerns often follow a pattern: a potential adverse effect is hypothesized; a premature announcement is made; the initial study is not reproduced; and finally, it takes several years to regain public confidence in the vaccine.
To allay the fears and reduce dropout rates, Government needs to establish a National Vaccine Injury Compensation Program to streamline the process for compensation for those who are injured due to vaccines as in the United states.
An open online registry for adverse reactions reporting for the public should be part of the Health system even in India similar to Countries like USA, UK. As the critics against vaccination have rightly pointed out, post marketing monitoring of adverse reactions should be done stringently. There is a recognition for the need for research on the true incidence of diseases like Chickenpox, Meningitis, Pneumococcal Pneumonia, Rotavirus diarrhea etc. in our country. We seem to rely totally on the figures of the West for introducing newer shots. Immunization programs depend on public confidence to be effective. Safety concerns often follow a pattern: a potential adverse effect is hypothesized; a premature announcement is made; the initial study is not reproduced; and finally, it takes several years to regain public confidence in the vaccine. A recent and notable example involved Andrew Wakefield's discredited claims of MMR vaccines causing autism.
Patients’ concerns about vaccine components need to be taken seriously. Provision of accurate, substantiated and unemotional information enables both health professionals and the public to make informed decisions concerning vaccination risk. It is criminal to deprive one’s child of the most basic and absolutely needed vaccinations. The message to anti vaccine protagonists is that today’s science is not emotive but rather evidence based!
Finally a word of caution: Criticizing the vaccines and immunisation strategies, by selectively quoting and highlighting few adverse reactions alone and feigning ignorance of its contribution towards overall benefit to mankind amounts to being perpetrators sabotaging the survival of mankind.
- World Health Organization. Vaccines, immunization and biologicals: diseases and vaccines. The history of vaccination. Available at: http://www.who.int/vaccines-diseases/history/history.shtm
- Offit PA, Jew RK. Addressing parents’ concerns: do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics 2003; 112: 1394-1397.
- Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351: 637-641.
- Murch SH, Anthony A, Casson DH, et al. Retraction of an interpretation. Lancet 2004; 363: 750.
- Bashir A, Asif M, Lacey FM, et al. Concordance in Muslim patients in primary care. Int J Pharmacy Pract 2001; 9(Suppl): R78.
- Novella S. The anti-vaccination movement. Skeptical Inquirer. 2013 Jul 3;31:26-31.
- Flaherty DK. The vaccine-autism connection: a public health crisis caused by unethical medical practices and fraudulent science. Annals of Pharmacotherapy. 2011 Oct 1;45(10):1302-4.
- Infectious Diseases and Immunization Committee, Canadian Paediatric Society (CPS). 2007. Autistic spectrum disorder: No causal relationship with vaccines. Paediatrics & Child Health 12(5): 393–95. Available at www.cps.ca/english/statements/ID/pidnote_jun07.htm.
- Islamic Organization for Medical Sciences. The use of unlawful or juridically unclean substances in food and medicine. Question 104. Islam SET [website]. Available at: http://www.islamset.com/qa/index.html
- Mynors G, Ghalamkari H, Beaumont S, et al. Informed choice in medicine taking. Drugs derived from pigs and their clinical alternatives: an introductory guide. London: Medicines Partnership, 2004. Available at: http://www.medicines-partnership.org/our-publications/drugs-of-porcine-o...