Why didn't you say "YES" Ben Carson?  A missed chance to set the record straight on MMR and Autism.

Why didn't you say "YES" Ben Carson? A missed chance to set the record straight on MMR and Autism.

Last night’s Republican debate featured many challenges and criticisms of the front runners by contenders as is typical of most such televised features.  Among the many topics discussed was the following exchange between Ben Carson a retired Neurosurgeon and Donald Trump.  While I am not an American, I believe both of them should be ashamed for putting children’s lives at risk by taking the “political road” and trying to play both sides.  Are the votes really worth it?  For a glimpse into the exchange see the following link.

The response by Ben Carson should have been much stronger and in giving a tepid answer (no doubt to appease the masses on the opposite side of the discussion) he let the medical establishment down.  Perhaps if Ben had read the following discussion on the topic he would have answered differently.

The Story of MMR and Autism

Children with autism may be healthy but life may be anything but easy.  WIth the receipt of any bad news comes different phases of emotion but one common reaction is search for answers.  Today I experienced an exchange of comments on Twitter from someone who disagreed with some comments I made with respect to giving the MMR vaccine.  The gist of it was that they had been the responsible parent, listened to the doctors of the world and given the MMR vaccine only to find out some time later that their child was diagnosed with autism.  I feel for this person and every other parent touched by this diagnosis.  It is devastating and life changing although with time and a lot of work such children can make great strides but sadly not all.

I understand then the fear of receiving such a diagnosis is a compelling reason to avoid getting vaccinated if there is even a chance that your child could develop autism.  You are wanting to protect your child and I commend you for that.  Unfortunately while trying to protect them you are in fact leaving them unprotected and for that matter the rest of the children in your community.  The aruguments against vaccinating with MMR centre around three major arguments. The first is that parents often recall receiving the vaccine shortly before the diagnosis of autism was given, the second that the literature supports that autism is caused by vaccines and the last that when the MMR vaccine was brought into existence autism rates started to rise.  Below I will address each point with factual information that I hope in some way will make an impact on those who hold onto the beliefs which is all they are that their child developed autism due to the vaccine.

Timing of the vaccine

Definition of autism (from Wikipedia):Autism is a neurodevelopmental disorder characterized by impaired social interactionverbal and non-verbal communication, and restricted and repetitive behavior. Parents usually notice signs in the first two years of their child’s life.[2] The signs typically develop gradually, but some children with autism will reach their developmental milestones at a normal pace and then regress.

Under a year of age language is fairly limited.  Social interaction, language and repetitive behaviours are typically noted after the first year of life.  Given the timing of the diagnosis and the provision of MMR at a year of age it is no wonder that parents will attribute the vaccine to the diagnosis.  Let’s think about this though for a minute.  What is happening here is confirmation bias.  As a parent you have heard that MMR can cause autism although thankfully it is quite rare but when you get the diagnosis you immediately jump to the conclusion that this is the true cause.  What you have is an association and nothing more but your mind has convinced you otherwise.  It equally could have been the new cookie you gave your child that month, the fumes from the car in a traffic jam or any other possible influence or it could be that it was always going to happen but as humans we need to make sense of things.  Its in our genes but it causes us to make a dangerous link that to be frank just doesn’t exist.

Autism is caused by the MMR vaccine

This argument centres around a extremely well cited paper that has been refuted. Andrew Wakefield published a link between autism and the MMR vaccine that set the world on fire.  The paper though was shown to be fraudulent and has been the subject of many publications since. retraction: http://bit.ly/1wb3Xjn

 Let’s think about this for a second.  What if this paper had never been published in the first place?  A link between vaccines and autism would not have been put in the minds of people such as Jenny McCarthy and other people outspoken against vaccines (she has since softened her stance).  In fact most people would not have even thought of such a link.  In essence the argument would not have even been present in pop culture and the wave of anti-vax literature would not exist.  Those young people who weren’t alive in the 1970s which is the time of our last point would not even be aware of the argument.  So the question is, if the lie had never been told would we even need to write pieces like this today?  Hard to believe people stand on an argument that was never meant to be in the first place.  To put it another way, if I published a paper that I confirmed a sample from the moon contained cheese and it spread throughout the media outlets of the world, if it was refuted would anyone actually cite it?  The fact is these people who are either scared of vaccines or have a child with autism need something to hang onto and this is it.

Autism rates increased after MMR came along

Again this is an association that people have attributed to be causative.  For a wonderful explanation of this phenomenon in the 1970s please read the article at this link: http://1.usa.gov/1MajxDf

Autism diagnoses did in fact rise but that had more to do with a change in the way doctors classified autism than any external factor.

What all three points have in common is that we as parents need to find order where there is disorder.  We also have the same drive as physicians to do no harm.  It is compelling and strong in all of us.  Each and every person who writes anti-vax literature I believe is not out to harm us but they truly believe that the reading they have done or the simple beliefs they have are the right ones.

What I ask is that people read a blog such as this and open themselves up to a paradigm shift.  If you can read what I have written and convert your thinking to one where you realize that all you have believed was based on poor information and switch to one in which your drive is protect your child by immunizing them your children and our children will all be better for it.

There may be a wrong time to vaccinate ELBW infants. The Healthy Vaccinee Effect

There may be a wrong time to vaccinate ELBW infants. The Healthy Vaccinee Effect

Ask any health care professional how our tinyest babies fare after an immunization and they will tell you “not well”.  In fact the belief is so pervasive that we go out of our way to find excuses to delay immunizations.  I have heard myself uttering such comments as “today is not a good day” or “let’s wait until there is greater respiratory stability” or simply “they are too sick”.  Perhaps this tendency develops because we are shaped by our past experiences and if we have had a baby get intubated who was on CPAP after an immunization, we subconsciously say to ourselves “that won’t happen again”.

By no means am I writing an anti-vaccination piece but rather exploring our behaviours and trying to come up with a means of changing them.  Adverse Events After Routine Immunization of ELBW Infants was published on this very topic this week and with nearly 14000 infants from 23 – 28 weeks included who received their first 2 month immunization, it certainly caught my attention!

The table indicates the risks of certain adverse events in the 3 days preceding the immunization to the 3 days afterwards. Table 2 What you will note is that the evaluations for sepsis increased 4X, Respiratory support and intubation almost 2X, with no difference in seizures.  It is important to note that the definitions for sepsis were based on two blood cultures being drawn rather than fever alone. Curiously with respect to sepsis there was an increase in the number of positive cultures as well from 2.1 to 3.8% in the evaluations that were done before and after.  It is worth pointing out though that I can find no analysis of those results to determine if they were statistically different so at most it is an “interesting” finding.

The figures below demonstrate the rate of the same adverse events before time zero and then afterwards for the same duration as in the table.
What you notice aside from the rise in adverse events is a sharp decline in the rate of adverse events just prior to the immunization and then a sharp rise after it is given. figure The steep decline just prior to immunization is known as the Healthy Vaccinee Effect. That is to say that we may see a higher rate of complications simply due to the fact that we wait for kids to be at their healthiest and when they have only had one or two days without apnea or are off their antibiotics that is when we choose to give the vaccine as we believe they can now “handle it”.  What we have created is a special sample of patients that actually does not reflect the whole population.  What I mean by this is that the response of all patients to their vaccines in this age group might be quite different with no increases in any adverse events if we paid no attention to our preconceived notions that the infant in our care is “too sick” to get their immunization.  When we only immunize those kids that are at their best, the likelihood of them deteriorating is higher than when they were “worse”.

We know from previous literature that ELBW infants have higher rates of apnea and need for respiratory support after their vaccines. If we gave them an immunization when they were on CPAP or a higher dose of caffeine would we notice the impact as much?  By waiting till they have weaned off CPAP or outgrown their dose of caffeine we are setting ourselves up for a setback.

Similarly perhaps the optimal time to give the vaccine is when they are actually on an antibiotic for a sepsis evaluation or have had a CRP for one reason or another in the preceding 24 hours.  Would a mild fever after the vaccine trigger the same response to do a septic workup or would you take comfort in knowing your patient was already on antibiotics or had no signs of inflammation prior to the vaccine?

In summary I question if I have had it all wrong.  I am not saying to give a vaccine to a patient who is on high frequency ventilation and inotropes due to septic shock but rather when they are recovering and off the inotropes but still ventilated what is the harm?  They are already intubated, and covered with antibiotics.  Seems to me to be the perfect conditions to prevent me from either escalating their respiratory support or doing a septic workup. They are already covered!

Routine childhood immunizations may improve your chances of beating cancer as an adult

Routine childhood immunizations may improve your chances of beating cancer as an adult

Brain cancer

The following piece is by my first guest blogger Dr. Simon Trepel MD, FRCPC whom I have known most of my life and am delighted to present his work here.  Simon is a Child Psychiatrist who has been touched by cnacer and has written a fascinating and touching piece below.

My wife, Kerri Tymchuk, died a bit over 2 years ago, at age 35, from metastatic breast cnacer. She left behind a loving husband and 2 beautiful daughters, ages 1 and 3, at the time of her death, at the claws of cnacer. I still can barely look at that word, or give it the decency of either spelling it correctly, or ever capitalizing it again. I remember having a similar reaction as a naive young child learning about the Jewish faith, and having a hard time with the word Jesus, as I could not reconcile a Messiah to come with one who had already come. Since then, Jesus and I are fine, and I am getting along well hoping for another. My point was that the word cnacer, to me, has become so strong, its power rivals the very existentialist crisis I had as a young boy.

The reason I am telling you this, is because anything relating to cnacer now sets off alarm bells in my head, as if my mortal enemy has mutated in rage again. I feel fear, and remember Kerri. And I whisper to her that she will be avenged when we learn which types of silver bullets work best on this beast that steals lives in every phase of the moon.

So I was captivated to learn on 60 minutes that there is a physician and research team that has seemingly discovered a possible miracle breakthrough in treating a very specific and deadly brain cnacer, called glioblastoma, or gb for short, spelled correctly. It seems that Dr. Annick Desjardins and the Duke cnacer Research Team have found that if you inject the polio virus directly into even the most aggressive gb tumors, the tumors replication, or ability to make unlimited copies of itself, is permanently stopped. It’s like unplugging cnacer’s Xerox machine. Once that happens, the polio virus then wreaks havoc in the gb cells themselves, and over the weeks and months to follow, your immune system beats up the schoolyard cranial bully until there is NOTHING LEFT.

Well, this got me thinking a bit about what we can do to potentially protect ourselves even better, in case we ever get gb ourselves, or it occurs, heaven forbid, in one of our children or extended family. The speed at which the cnacer cells in gb are destroyed depends on the immune system of white blood cells and other special cells. Some of these immune cells remember very well the viruses that egged the front porch of our face with a head cold or caused pneumonia or fever. If that same bacteria or virus comes around again, the immune system is exponentially better at mounting a response and ending the illness much quicker. The immune system also has the ability to recognize and destroy cnacer cells. Most cnacers are tricky, and go unnoticed in your body, wearing a disguise with a name tag that says ‘please look away while I kill you’. Incredibly, the polio virus, once it affects gb cells, seems to pull the mask off, and once this occurs, your own personal secret service, the immune system, rushes in, and blasts the cnacer dead like 007 (at least so far in the more than dozen formerly terminal patients who have responded to this form of treatment) .

The punch line of this short essay is to say that right now, you have the ability to potentially greatly improve your chances of surviving cnacer! At the very least, this breakthrough has been demonstrated in a highly malignant (able to double in size every 2 weeks) form of cnacer. If infecting other types of cnacers in a similar way, or with a different virus, also works, we may have a bona fide potential cure for cnacer on our hands. And our loved one’s can stay longer to live their lives.

This is not an infomercial for a new tropical berry juice or something that Jenny McCarthy is going to like. Getting immunized as a child with the regularly scheduled polio vaccination causes your immune system to recognize and destroy ANY cell (including cnacer cells) that have been infected with polio. Your immune system will respond more efficiently and faster, compared to never being immunized against polio. If infecting other types of cancers shows the same result, you may immediately get a huge head start on your future cnacer treatment by ensuring that you and your children are immunized according to the Health Canada Vaccination Schedule. For those anti vaccination people out there, at least consider the polio one. Once you are vaccinated against polio, your immune system will act like it is on steroids (the Ben Johnson kind) and you will beat polio infected glioblastoma, or perhaps all cnacers, in a similar fashion.   Please think about it.

A sympathetic note to the antivaxxers of the world

3.3.5_vaccination

I have two healthy children who make friends easily and excel at most tasks put before them.  Children with autism may be healthy but life may be anything but easy.  WIth the receipt of any bad news comes different phases of emotion but one common reaction is search for answers.  Today I experienced an exchange of comments on Twitter from someone who disagreed with some comments I made with respect to giving the MMR vaccine.  The gist of it was that they had been the responsible parent, listened to the doctors of the world and given the MMR vaccine only to find out some time later that their child was diagnosed with autism.  I feel for this person and every other parent touched by this diagnosis.  It is devastating and life changing although with time and a lot of work such children can make great strides but sadly not all.

I understand then the fear of receiving such a diagnosis is a compelling reason to avoid getting vaccinated if there is even a chance that your child could develop autism.  You are wanting to protect your child and I commend you for that.  Unfortunately while trying to protect them you are in fact leaving them unprotected and for that matter the rest of the children in your community.  The aruguments against vaccinating with MMR centre around three major arguments. The first is that parents often recall receiving the vaccine shortly before the diagnosis of autism was given, the second that the literature supports that autism is caused by vaccines and the last that when the MMR vaccine was brought into existence autism rates started to rise.  Below I will address each point with factual information that I hope in some way will make an impact on those who hold onto the beliefs which is all they are that their child developed autism due to the vaccine.

Timing of the vaccine

Definition of autism (from Wikipedia):Autism is a neurodevelopmental disorder characterized by impaired social interactionverbal and non-verbal communication, and restricted and repetitive behavior. Parents usually notice signs in the first two years of their child’s life.[2] The signs typically develop gradually, but some children with autism will reach their developmental milestones at a normal pace and then regress.

Under a year of age language is fairly limited.  Social interaction, language and repetitive behaviours are typically noted after the first year of life.  Given the timing of the diagnosis and the provision of MMR at a year of age it is no wonder that parents will attribute the vaccine to the diagnosis.  Let’s think about this though for a minute.  What is happening here is confirmation bias.  As a parent you have heard that MMR can cause autism although thankfully it is quite rare but when you get the diagnosis you immediately jump to the conclusion that this is the true cause.  What you have is an association and nothing more but your mind has convinced you otherwise.  It equally could have been the new cookie you gave your child that month, the fumes from the car in a traffic jam or any other possible influence or it could be that it was always going to happen but as humans we need to make sense of things.  Its in our genes but it causes us to make a dangerous link that to be frank just doesn’t exist.

Autism is caused by the MMR vaccine

This argument centres around a extremely well cited paper that has been refuted. Andrew Wakefield published a link between autism and the MMR vaccine that set the world on fire.  The paper though was shown to be fraudulent and has been the subject of many publications since. retraction: http://bit.ly/1wb3Xjn

 Let’s think about this for a second.  What if this paper had never been published in the first place?  A link between vaccines and autism would not have been put in the minds of people such as Jenny McCarthy and other people outspoken against vaccines (she has since softened her stance).  In fact most people would not have even thought of such a link.  In essence the argument would not have even been present in pop culture and the wave of anti-vax literature would not exist.  Those young people who weren’t alive in the 1970s which is the time of our last point would not even be aware of the argument.  So the question is, if the lie had never been told would we even need to write pieces like this today?  Hard to believe people stand on an argument that was never meant to be in the first place.  To put it another way, if I published a paper that I confirmed a sample from the moon contained cheese and it spread throughout the media outlets of the world, if it was refuted would anyone actually cite it?  The fact is these people who are either scared of vaccines or have a child with autism need something to hang onto and this is it.

Autism rates increased after MMR came along

Again this is an association that people have attributed to be causative.  For a wonderful explanation of this phenomenon in the 1970s please read the article at this link: http://1.usa.gov/1MajxDf

Autism diagnoses did in fact rise but that had more to do with a change in the way doctors classified autism than any external factor.

What all three points have in common is that we as parents need to find order where there is disorder.  We also have the same drive as physicians to do no harm.  It is compelling and strong in all of us.  Each and every person who writes anti-vax literature I believe is not out to harm us but they truly believe that the reading they have done or the simple beliefs they have are the right ones.

What I ask is that people read a blog such as this and open themselves up to a paradigm shift.  If you can read what I have written and convert your thinking to one where you realize that all you have believed was based on poor information and switch to one in which your drive is protect your child by immunizing them your children and our children will all be better for it.

Keeping infants sweet and warm for immunization.

Keeping infants sweet and warm for immunization.

Sucrose given to newborns prior to anticipated painful procedures has been used for many years now.  The pooled evidence as presented by the Cochrane Database of Systematic Reviews concludes that “Sucrose is safe and effective for reducing procedural pain from single painful events (heel lance, venepuncture).”  As care providers for newborns in an Intensive care setting we have become accustomed to providing this sugar to infants prior to such procedures and there is no question that we note the benefit in both subjective assessment of pain and when using more objective scoring systems.

It is for this reason that I read with great interest the article by Gray L et al Pediatrics entitled Sucrose and Warmth for Analgesia in Healthy Newborns: An RCT.   The study included 29 infants roughly half of which were randomized to sucrose 1 mL/kg of a 25% solution (Sweet-Ease) and the other to the same solution plus placement on an overhead warmer prior to Hepatitis B immunization.  The results demonstrated a reduction in crying with both interventions compared to the sucrose alone as shown in the following figure.

Untitled

An additional finding was that of a dampening of heart rate acceleration if the infant received warmth as well.  There is no question that the combination of warmth and sucrose is superior to providing sucrose alone but is the study relevant today?

The infants in this paper were recruited in 2008 at a time when we as a profession were not as accustomed to Kangaroo Care or Skin to Skin care as it is also known.  In the study the overhead warmer was used as a substitute for Skin to Skin care but in 2016 would we do this?  Perhaps if the mother was unavailable but certainly not if we could put the infant against the mother’s chest and provide sucrose.  While the study has its merits I think it fails a critical test in order to apply it in our own practice.  The question must always be asked no matter what the size of an effect “Can the results of the study be applied to my patient population?”

I fear in this case the answer is no for most of our infants.  The paper serves as a good reminder that while results of a study may be valid, they might just not be useful in your own practice.

Antipyretics or Sucrose for Vaccine Related Pain?

Future questions though that come to mind are whether sucrose analgesia may be useful in older children at 2,4 and 6 months.  Previous research has demonstrated that while fever may be effectively treated with prophylactic antipyretics the additional finding is that of reduced antibody production to some vaccine antigens.  While a reduction has been noted, even with reduced levels protection remains as the threshold for immunity is not crossed.  This has been evaluated in a systematic review in 2014 pertaining to the same topic.  As some practitioners though now advise against such prophylaxis might sucrose be the replacement?  This has been studied in 16-19 month olds receiving a series of vaccinations and found to be an effective pain reliever as demonstrated in the paper Oral sucrose administration to reduce pain response during immunization in 16-19-month infants: a randomized, placebo-controlled trial.  While the results of the study demonstrate effectiveness to reduce pain the effect on the immune response remains unanswered.

What the future will hold I don’t know but if you are looking for another option for pain relief other than acetaminophen or ibuprofen you may wish to ask your practitioner about a little sugar next time.

 

A word of caution about Kristin Bell's recent statement on pro-vaccination

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What?!  A doctor speaking out against pro-vaccination?  No I haven’t switched to the other side but a recent headline caught my eye due to its potential to create a social crisis.

Imagine you have just had a baby and friends of yours who you know have not vaccinated her children want to come by for a visit. (see link)  Do you freak out and deny them entry as Kristin Bell would suggest or do you ask a few questions (more delicately than “do your children have measles” and allow the visit to happen?

It seemed like a good opportunity to calm people’s nerves by reminding them of why it is that your Pediatrician will not offer the MMR vaccine prior to the age of 1 year.  If you have been vaccinated as a child then you generally will have lifelong immunity to measles.  The Centre For Disease Control claims that the immunity is 95% after one dose and virtually 100% after the booster dose to measles, mumps and rubella.  If the vaccine though is so effective why not give it before a year to protect your vulnerable infant? The answer lies in the natural immunity that is passed from mother to fetus in the form of IgG antibodies that cross the placenta.  These antibodies offer protection to the fetus and then newborn and may circulate in the infants bloodstream until 1 year of age.  In essence your infant is protected from measles by virtue of your parents being sensible and vaccinating you when you were a child.  The benefits of breastfeeding by passing on further antibody protection are additive (see link)!

So before anyone accuses me of being careless let me restate that I would not expose my own child under a year of age to a child that was suspected of having measles but I often worry about the effect of one celebrity sharing information such as this and the social isolation that may ensue for those parents who choose for whatever reason not to immunize.  Let us also not forget that there are legitimate reasons for not immunizing your children and should these children be ostracized?

Links:

http://www.huffingtonpost.com/2015/02/17/kristen-bell-vaccinations_n_6699368.html

http://www.ncbi.nlm.nih.gov/pubmed/19133867