Vaccines have been widely heralded by the scientific community and public health officials as one of the greatest medical breakthroughs of the modern era. Their importance cannot be understated -- vaccines have saved hundreds of millions of lives since they were first introduced in the 18th century. Smallpox, a disease caused by the variola virus, had existed for at least 3,000 years and was one of the world’s most feared diseases until it was eradicated by a collaborative global vaccination program led by the World Health Organization. The last known natural case was in Somalia in 1977.
But vaccines can only reach their full potential if enough people are inoculated to stop highly dangerous pathogens from spreading. In some places of the world, poverty, dirt, and weak governance are the biggest allies of infectious diseases, while in developed, affluent, and supposedly educated countries, their biggest ally is the global anti-vaccination movement.
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Consequences of the vaccine scare
In the United States, all states require vaccinations for children to be allowed to enroll in school. However, 18 states allow parents to opt out of vaccinations for their children based on personal beliefs.
Some parents forgo vaccinating their children for economic reasons -- perhaps they can't afford the insurance or a trip to the doctor. This explains why, generally speaking, vaccination rates are lower for children living in poverty compared to those who aren't. A very small percentage of the population has to skip vaccines for medical reasons -- such as when a child has a compromised immune system. Others opt out of vaccines for their children for religious considerations. And there's an important and growing subgroup of people who resist vaccines out of the pseudoscientific notion that vaccines somehow cause autism -- a fraudulent claim that has been debunked by many independently researched studies, but whose ripples still shake society.
A 2013 paper established a link between falling immunization rates and the recent resurgence of vaccine-preventable diseases. California, for instance -- a hub for the anti-vaxxing movement -- saw 9,120 cases of whooping cough (pertussis) in 2010, which more than any year since the whooping cough vaccine was introduced in the 1940s. During this particular outbreak, ten infants died of whooping cough.
According to a 2016 report issued by the American Academy of Pediatrics (AAP), vaccination will prevent about 322 million illnesses among children born between 1994 and 2013. However, a high-profile resistance to vaccination, such as the one we're currently experiencing, will lower this prevention rate. Already, the increase in unvaccinated children has contributed to a return of dangerous diseases like measles and whooping cough.
The AAP found that in 2013, 87% of pediatricians said they had encountered a parent who refused to vaccinate their child, up from 75% in 2006. During the same time period, the number of parents that refused all vaccines increased from 2.1% to 3.3%.
What's staggering about the report's findings is that most pediatricians worked with parents who refused vaccines because they felt they were unnecessary (73% in 2013, up from 63.4% in 2006). Yes, you've read that right -- it's wasn't money, politics, god, or fear of autism that made these parents resist vaccination; it was just plain old ignorance. It boggles the mind that some parents feel vaccination is unnecessary because they don't hear about anyone getting sick, failing to recognize that no one gets sick because they're vaccinated in the first place.
In somewhat good news, fewer doctors encountered concerns over autism in 2013 (64.3%, down from 74.2% in 2006). However, this number may have changed for the worse in the years since the statistics were gathered.
Perhaps the most important piece of information from the report is that ignorance can be swayed. Of those who initially refused vaccination but were handed out educational materials by their pediatrician, 34.4% changed their mind in 2013.
Anti-vaxxers myths debunked
Opposition to vaccines has been around as long as vaccinations themselves. When Boston physician Zabdiel Boylston began rubbing slices from smallpox sores into open wounds to try to protect the healthy from outbreaks in the early 1700s, there was immediate resistance to his then-unproven inoculation method.
Although vaccines have proven themselves as one of the greatest public-health achievements of the 20th century, people throughout history have found various reasons to distrust them. Some found it too counter-intuitive that exposure to a disease could provide protection, others felt vaccination violated God’s will, and others simply felt that mandatory vaccination policies violated personal liberty. In a sense, today's vaccine-related "urban myths" are the manifestation of a longstanding distrust of inoculation.
Today, the CDC vaccination schedule calls for children to receive up to 14 inoculations by the age of six. Many parents, unfortunately, resist vaccinating their children due to a number of modern misconceptions about vaccine safety largely perpetuated over social media that keep parents from vaccinating their children.
Myth #1: A child's immunity needs to develop naturally
Vaccines, in fact, strengthen the immune system. Because they introduce a weakened form of a virus into the body, vaccines help the immune system by teaching it to identify and defend against infections in the future.
Children need to be vaccinated at a young age because that's when their immune system is the most susceptible. However, young and old people alike need an immune system boost with a vaccine.
While it's true that catching a disease and getting sick -- what we mean by natural immunity -- results in a stronger immunity to disease than a vaccination would offer, the dangers are simply far too great to outweigh the relative benefits. For instance, a child could very well acquire immunity to measles by contracting the disease, but in doing so risks a 1 in 500 chance of death. In contrast, the chance of developing a severe allergic reaction to an MMR vaccine is less than one in a million.
Myth #2: Vaccines contain toxic chemicals such as mercury, aluminum or formaldehyde
While it's true that vaccines contain potentially toxic substances like aluminum and formaldehyde, these chemicals become toxic to the human body only past certain levels. "The dose makes the poison" is an old adage in pharmacology, a cornerstone of medicine to this day. For instance, common salt (sodium chloride), which is essential for normal functioning of the body, is harmful in large quantities. Likewise, very low amounts of certain metals are non-toxic, but in high amounts they can be devastating.
All vaccine ingredients are present in very small quantities, and there is no evidence that any of them cause any harm in these amounts. Aluminum is present at about 0.125 mg per dose, whereas an average human consumes 30 to 50 mg each day. Mercury used to be present in equally negligible amounts, but due to public outrage, it was removed entirely from vaccines in 2001.
Formaldehyde can be toxic in large quantities, but it's safe in small quantities and is actually in many foods we consume. A vaccine contains only 0.1 mg of formaldehyde, which is far less than what can be found in fruit or the human body. Consider that the human body makes 500 mg of formaldehyde a day for DNA synthesis.
Myth #3: A baby's immune system can't handle that many vaccines
Infants might seem fragile, but their immune system isn't. On any given day, a child will fight between 2,000 and 6,000 immune challenges, which is far more than the number of antigens or reactive particles in all of the 14 scheduled vaccines combined. Even if a baby were to take them all at once, the vaccines would only slightly use the baby's immune system -- less than 0.1% of its total capacity.
Immune capacity is a theoretical construct in the first place. In reality, an immune system could never be overwhelmed because the system's cells are constantly being replenished. Bottom line: immunizations are negligible in comparison to the countless bacteria and viruses that a baby fights off every day.
It should also be noted that while infants today receive more vaccines than they did in the past, today's vaccines are far more efficient and contain fewer immunologic components. For instance, in the 1960s, vaccines contained up to 3,200 proteins while today that number hovers at around 125.
Myth #4: The side effects aren't worth it
Children have been vaccinated for decades and, despite what you may have read, there is no one reputable source or credible study linking immunization to long-term health problems.
The worst that can happen is the infant might suffer a mild fever or sore arm, but these side effects are temporary. On a very rare occasion -- 1 in 1,000,000 in the case of the MMR vaccine -- a child might experience a non-fatal severe allergic reaction to the vaccine, but as stated earlier that's far better than risking the alternative of infection. Only one vaccine-related death was reported by the CDC between 1990 and 1992.
Myth #5: Hygiene and better sanitation are responsible for the drop in infections, not vaccines
Anti-vaxxers will often discredit the value of vaccines, stating that better sanitation, nutrition, and antibiotics are what actually drove down deadly infections. While these socioeconomic elements are important and significantly lowered the population's death rate, their effect on infectious diseases isn't nearly as great as that of vaccines. It was a vaccine, not running water and soap, that eradicated polio. Prior to the introduction of the measles vaccine in 1963, the rate of infection held steady at around 400,000 cases per year. Hygienic habits and sanitation changed very little up until 1970, the year when only 25,000 cases were reported.
Myth #6: Vaccines infect children with the diseases they're supposedly trying to prevent
Some vaccines can lead to mild symptoms resembling the infections they are designed to prevent. This is an established fact, but it is easy to see how this can be misinterpreted. In the very rare cases where these symptoms occur, the person's immune response is to the vaccine's content, not the disease itself.
For instance, the MMR vaccine contains a weakened (or attenuated) but still live measles virus and can cause a rash in about 5% of people. This rash typically occurs one week after immunization. However, the vaccine does not trigger symptoms like inflammation of the middle ear or lung -- both hallmarks of the actual disease.
There is only one instance in which a vaccine was shown to cause disease -- the Oral Polio Vaccine (OPV), which in some cases caused patients to develop poliomyelitis due to the live virus being used. OPV is no longer used and was replaced by an injection that doesn't contain live viruses.
Myth #7: Vaccines are a conspiracy designed by big pharma for profit
Pharmaceutical companies make money from vaccines, that goes without saying. So do food companies and automakers from their respective products. Vaccines are an essential component of modern civilization, so of course, there will be private capital invested in filling this societal need.
It has to be said that vaccines are sometimes extremely expensive to produce and, in the US, it takes 10-25 years just to get one vaccine approved. In fact, for decades the vaccine industry had struggled with very slim profit margins and some proved so unprofitable that they were ultimately driven off the market.
Compared with drugs that require daily doses, vaccines are only administered once a year or once in a lifetime. This offers far less economic incentive than daily drug treatments. The Economist wrote that "for decades vaccines were a neglected corner of the drugs business, with old technology, little investment and abysmal profit margins. Many firms sold their vaccine divisions to concentrate on more profitable drugs."
Fortunately for the vaccine industry, the market was turned around by increased global demand, particularly in developing countries. However, developing a new vaccine is still an extremely risky undertaking for pharmaceutical companies even to this day. Meanwhile, society gains an estimated return of $16 for every dollar invested in immunization.
Myth #8: People have the right not to vaccine themselves (or their children) because it's their body
This is a common misconception. Vaccines are designed to protect you but are just as important for protecting those around you -- especially vulnerable groups like the elderly or those who can't be vaccinated due to medical considerations. By choosing not to vaccinate, you put others at risk, which interferes with their right to a healthy life. Being vaccinated is the responsible thing to do, and in some places, it is mandated by law. In some US states, children cannot access public schools without being vaccinated and in Australia compliance with childhood immunization schedules has been linked to pre-school admission (‘No jab, no play’) and to family assistance payments (‘No jab, no pay’).
Myth #9: Vaccines are no longer required -- there aren't any diseases!
As the APP mentioned in the previous chapter highlights, a growing number of people refuse to vaccinate their children because they think it's unnecessary. Why bother?
Well, just because there's no more polio in the United States doesn't mean you can't get infected. Polio is still around and could easily start re-infecting unprotected individuals when re-introduced to the country. A better example is measles, which was very rare in the United States until outbreaks occurred as a result of Americans traveling to countries where the disease remained widespread. When there are adequate vaccination rates, most types of outbreaks can be prevented.
Myth #10: Vaccines cause autism
Yes, we saved the best for last.
This association first sprouted in the public's mind in 1998 when Andrew Wakefield, a British surgeon, published a study in the prestigious medical journal, The Lancet, suggesting that the measles, mumps, rubella (MMR) vaccine was increasing autism in British children. Since then, the paper has been completely discredited, with several investigations proving that the study fabricated data and that Wakefield had financial incentives to publish rubbish. The whole study was a fraud, basically. The doctor lost his license and the paper was retracted from the journal -- but the damage was already done.
Since Wakefield's paper, many major studies -- this time carried out under ethical conditions and by capable people -- have investigated the link between any vaccine and the likelihood of developing autism. Not a single study found a connection between the two.
The true cause of autism remains a mystery, but vaccines seem very unlikely to be involved. Studies have shown that symptoms of autism develop in children before they receive the MMR vaccine and even well before the baby is born.
But since the vaccine and autism link is the most cited pseudoscientific claim in the anti-vaxxer's arsenal, this myth deserves a more in-depth look.
The Wakefield fraud, or how a scientist tricked millions into thinking vaccines cause autism
Andrew Wakefield and 12 co-authors published a small case series finding a link between measles-mumps-rubella vaccine (MMR) vaccination and autism in children. Although the paper itself did not demonstrate a causal relationship between MMR vaccination and autism, Wakefield released a video coinciding with the paper's publication that a causal relationship did, in fact, exist.
“[…] the risk of this particular syndrome [what Wakefield termed autistic enterocolitis] developing is related to the combined vaccine, the MMR, rather than the single vaccines," Wakefield stated.
This assertion, in and of itself, was enough to raise a lot of red flags to anyone somewhat scientifically literate.
Earlier, in 1995, Wakefield and co-authors published a cohort study showing that individuals who had been vaccinated with MMR were more likely to have bowel disease than those that were not vaccinated. Wakefield speculated that the link might be mediated by a persistent infection with the vaccine virus that disrupted intestinal tissue and, in turn, caused bowel disease -- as well as autism.
Considerable attention was devoted to the publication of Andrew Wakefield's article by the media because it rang an emotional chord with the public (i.e. fear). But the widespread news also perpetuated the "urban legend" that vaccines cause serious neurological disorders and boosted anti-vaccination associations.
Following an investigation conducted by the investigative journalist Brian Deer in 2004, the British Medical Journal concluded that Wakefield's study linking vaccines to autism was a "deliberate fraud". Deer's investigation showed that Wakefield altered numerous facts about the patients’ medical histories in order to support his claim to have identified a new syndrome, that the Royal Free Hospital and Medical School in London (Wakefield's parent institution) supported him as he sought to exploit the ensuing MMR scare for financial gain, and that key players failed to investigate thoroughly in the public interest when Deer first raised his concerns.
According to Fiona Godlee, the editor in chief of the BMJ, the article by Wakefield "was based not on bad science but on a deliberate fraud," pointing out that in Wakefield's research:
only one of the nine children who allegedly had autism really did;
five of the children had developmental difficulties before vaccination, although the article claimed that all were in good health before vaccination.
Although the paper claimed that a mean time of 6.3 days elapsed between vaccination and the onset of symptoms, some children had their first symptoms months after vaccination.
Furthermore, many studies carried out after the publication of the paper demonstrated without any doubt that MMR vaccines do not engender a higher risk of autism or colitis. The US Institute of Medicine (IOM) also concluded that "the evidence favors rejection of a causal relationship between MMR vaccine and autism."
Wakefield seems to have had a financial interest in promoting his falsified views, having recommended that the MMR vaccine should be suspended in favor of single-antigen vaccinations given separately over time. In 1997, one year prior to the publication of his controversial paper, Wakefield applied for a patent for a single-antigen measles vaccine. It was later revealed that Wakefield was also paid by attorneys seeking to file lawsuits against vaccine manufacturers.
The discredited scientist was given ample opportunity to replicate the findings of his controversial paper or to admit that he was mistaken -- after all, as part of the scientific method, there's nothing wrong with re-evaluating your hypothesis in the face of conflicting evidence: that's how science works. But Wakefield did neither, repeatedly denying he had done anything wrong.
In 2010, the paper was officially retracted by the Lancet, and Wakefield was stripped of his clinical and academic credentials. To this day, however, Wakefield hasn't admitted to any fault -- actually, he's still at large perpetuating the false views that vaccines cause autism.
The reality is that the relationship between vaccinations and the onset of serious neuropsychiatric diseases is certainly one of coincidence rather than causality. Most autism researchers hold that the causes of autism are many and include genetic and environmental factors, but do not involve vaccines.
But despite the fact that Wakefield was exposed as a fraud and subsequent studies failed to establish any link between autism and vaccines, the damage to public health was immense and continues to this day. Fuelled by unbalanced media reporting and a poor response on behalf of the government, journals, and the medical profession in general, many frightened parents began to delay or completely refuse vaccination for their children. To ensure 'herd immunity', the World Health Organization recommends vaccination rates of at least 95% but in some places, such as the United Kingdom, vaccination rates were as low as 80% in 2003-2004. In 2008, for the first time in 14 years, measles was declared endemic in England and Wales.
The MMR and autism study was just the one most recent high-profile papers in a long string of alleged adverse events of vaccination. This speculation is linked to the fact that the true causes of many neurological conditions, such as Alzheimer's disease or autism, are largely unknown.
The "urban legend" concerning the association between influenza vaccination and Alzheimer's disease appeared in 2005 after an episode of the television show "Larry King Live" in which Dr. Bill Maher was being interviewed by Larry King. Maher argued that "if you have a flu shot for more than five years in a row, there's ten times the likelihood that you'll get Alzheimer's disease." Maher was quoting the supposed findings of Hugh Fudenberg presented during a speech at the 1st annual International Public Conference on Vaccination, which was held by the National Vaccine Information Center in Arlington, Virginia in 1999. However, Maher should have known better, because, in 2001, a cohort study on dementia had shown that increased exposure to vaccines against diphtheria, tetanus, polio, and flu was not a risk of contracting Alzheimer's and was found to potentially protect against the disease.
In 1991, an article published by Herroelen et al. concluded that people were at risk of developing multiple sclerosis six weeks after the administration of the DNA-recombinant vaccine against hepatitis B. The findings, which could not be replicated by later studies, caused a considerable scare among the public, significantly lowering vaccination rates.
In 1974, Kulenkampff et al. published a study on an uncontrolled case series which reported mental retardation and epilepsy in children who had received a whooping cough vaccine. Subsequently, in Britain, pertussis vaccination coverage plummeted from 83% to 31%, resulting in more than 100,000 cases of pertussis and 36 avoidable deaths in the country. In Japan, pertussis vaccination was suspended altogether, with the proportion of immunized children dropping from 70% to 20%, while cases of pertussis increased from 393 (0 deaths) in 1974 to 13,000 (41 deaths) in 1979.
There was also a hypothesis linking the MMR vaccine to epilepsy, but a 2004 study that sampled 439,251 Danish children concluded that there was no evidence of a statistically significant association between the two.
How to reason with the anti-vaxxing movement
Confronting a person with anti-vaxxing views can be a frustrating experience. In fact, research suggests that presenting facts that refute a conspiracy will likely strengthen a person's existing beliefs. So if hard facts, such as the myriad I've listed in this article, don't seem to work, what can we do?
Although refusing to vaccinate is irresponsible and constitutes a public health hazard, people who choose this route aren't necessarily bad people. Just like most other people, anti-vaxxers care deeply about the health and safety of their children and are driven by morals. People vaccinate their children because they are convinced this is the right thing to do for their children; for the same reason, anti-vaxxers choose not to vaccinate.
According to a paper published in the journal Nature Human Behaviour, when compared with parents who approve of vaccines, parents who are most reluctant to vaccinate are strongly concerned with liberty and purity. In this particular context, liberty is associated with belief in personal responsibility, freedom, property rights, and resistance to state involvement in citizens' lives. Purity refers to boundaries and protection from contamination.
Most public health messages often rely on facts and science to explain how immunization works. The assumption is that if we put all the facts on the table, this will change minds. However, this isn't particularly effective because people don't make decisions solely based on facts.
Facts are, of course, important, but incorporating morals could help improve public health communication. For instance, a doctor could focus more on addressing 'purity' values when speaking with a mother who is concerned about the chemicals found in vaccines. Perhaps the doctor could explain how a vaccine actually keeps a child pure from diseases. Liberty-orientated messages could, for instance, inform parents how vaccines help children live a healthy life free of disease.
Another study published in the journal PNAS found another tactic that is particularly effective at changing people's minds -- stop arguing and let pictures do the talking. The 2015 study recruited 315 people with anti-vaxxing views who were separated into three distinct groups. One was given facts on the safety of vaccines from the Centers for Disease Control and Prevention (CDC), another was asked to read an unrelated statement about bird feeding, and the third was shown photos of vaccine-preventable diseases along with the personal account of a woman whose 10-month-old son almost died from measles.
Surprisingly, the bird feeding statement had as much of an effect on the anti-vaxxers as the CDC facts -- that is, no influence at all. The third approach, however, which showcased graphic photos and accounts of people infected with diseases such as measles and smallpox, managed to sway people to have a more positive attitude towards vaccines.
"It’s sort of appealing to directly confront people about their beliefs, but that sets up a context for an argument, and then they respond by arguing back," one of the researchers, Derek Powell from the University of California, Los Angeles, told Vocativ. "If you tell people that these are contagious diseases and that there are serious benefits to getting vaccines, you can get improvements in people with negative attitudes toward vaccines."
The research suggests to find a common ground with anti-vaxxers by focusing on the positives of vaccination, instead of being confrontational, is a far more effective tactic.
"It’s more effective to accentuate the positive reasons to vaccinate and take a non-confrontational approach - 'Here are reasons to get vaccinated' - than directly trying to counter the negative arguments against vaccines," lead researcher on the study Keith Holyoak said in a press release. "There was a reason we all got vaccinated: Measles makes you very sick. That gets forgotten in the polarising debate on whether the vaccine has side effects."
The battle to restore parents' trust in vaccines is ongoing, but with so much misinformation out there, it’s certainly a challenge. No one can deny that some old vaccines, such as those against rabies and smallpox as well as the oral polio vaccine, could cause serious, albeit rare, neurological reactions. However, in the 21st century, vaccines are far more advanced in terms of design, development, and quality control.
Vaccines have stood the test of time and the safety of modern inoculation is undisputed by any reputable source. At the end of the day, it's a matter of trust -- and who would you trust more: the global medical community or some quacky soccer mom on Facebook? I rest my case.