Vaccine Education Vaccine Course https://www.storybookpeds.com/wp-content/uploads/2020/11/Vaccine-Education-Course.m4a How, why, when, and for what we vaccinate today starts with the story of smallpox, polio, and diptheria. Our whole understanding of how vaccine immunity works began with the discovery of the relationship between smallpox and cowpox. This one thing alone resulted in an inestimable number of lives saved in the last two hundred years. This course is designed to give accurate information for parents. We recognize (and support) the right to refuse vaccines contrary to medical advice. But we also know that many times parents seem to opt out because they don't know the facts about what vaccines do, what they actually contain, and why we think they are so important. It is best viewed on a desktop computer, and I strongly encourage you to take notes. I do not suggest that children view the content! After you view all the slides, you'll end up back here where you can click on the button to take the quiz. There are 20 questions pulled randomly from a pool of over 80. Some questions are worth more points. You can view the slides anytime and take the quiz as many times as you need to. Any video material will NOT be on the quiz. Let's dive in! Finished The Slides! I'm Ready To Take The Quiz. Smallpox VirusSmallpox is estimated to have killed 300 to 500 million people worldwide over the history of the infection. There are two forms resulting from slightly different strains of the virus, and one is much more serious than the other. Exposure occurs from direct, prolonged personal contact with body fluids. Even today, the simple lack of understanding of general contagion along with the various day-to-day local geographic practices propel the spread of disease this way. Ebola is a prime example. It took a lot of education to break social mores about handling the bodies of those who died from it. Similar to measles, smallpox incubation averages 12 to 14 days and ranges from 7 to 17 days. Raised bumps develop and progress to pus-filled blisters that crust and scab, eventually leaving a pitted scar. Like the flu, smallpox begins with high fever, headache and body aches, and sometimes vomiting, making it difficult to distinguish between them and prevent spread early on. It kills 30% of those it infects and has the highest mortality rate of any virus. It was finally declared eradicated from the wild in 1980. Corneal UlcerationsAmong the 70% of infected individuals that survived smallpox, corneal ulcerations and blindness was a common occurrence. This resulted in permanent damage and even blindness. Smallpox was a serious scourge then. Because we don’t see it in the wild today, the significance of vaccines is more easily discounted. Outbreaks occurred everywhere, and many efforts to fight smallpox were local. The background image shows vaccination on a train in Montreal, Canada bound for the US. Were smallpox to reemerge in the world, the landscape of anti-vaccine sentiment would change overnight. It would dwarf the SARS-CoV-2 pandemic. Edward Jenner (1749-1823)The story of how we defeated the virus started with Edward Jenner and English milkmaids a hundred years earlier. Milkmaids contracted from milking cows infected with cowpox. Symptoms were similar to smallpox, but it was not fatal. Jenner (and others) noticed that milkmaids who had already been infected with cowpox were immune to smallpox. Sarah Nelmes was such a milkmaid. On May 14, 1796, Jenner applied material from one of Sarah’s hand lesions to two superficial incisions on 8-year-old James Phipps, a child who had never had smallpox. James developed evidence of infection, which was slight, and quickly recovered. On July 1, 1796, Jenner then exposed James to smallpox, but he did not develop the disease. He published his account, and that is where cowpox got the official name “variolae vaccinae.” The term “virus” came from Roman times and referred to a noxious agent or poison. No one knew what a virus was at that time, however. Infectious agents were simply known to cause disease by spreading from infected people to uninfected people. What Jenner had discovered was that cowpox and smallpox were of such close molecular similarity, that infection with the milder cowpox prevented the more serious infection of smallpox. It was Jenner who coined the terms vaccine and vaccinations. Smallpox VaccinationThe current smallpox vaccine is not manufactured with the actual smallpox virus. It is made from live Vaccinia virus which is similar to both cowpox and smallpox. This vaccine was not given subcutaneously or intramuscularly like most vaccines are today. It was first administered with a special double-pointed needle dipped into the vaccine solution. The site of the multiple needle pricks to the skin becomes a weepy blister that scabs over after a week. The lower image shows the double vaccination needle that was initially used to vaccinate individuals. The upper left image is the typical reaction to that vaccination. The top right image is my own vaccination scar. We know today that those vaccinated like me probably retain immunity from smallpox for about seven years. Vaccine OppositionVery few experienced symptoms beyond the funny-looking vaccination scar. The 30% mortality of the disease greatly overshadowed any vaccine. Nevertheless, there was no small amount of controversy even then, as you can see from this old parody of the vaccine. Edward Jenner had a very personal interest in smallpox, which led him in his effort to vaccinate for it. He was born in 1749, orphaned at age 5. When he was a child, it was first postulated that by intentionally infecting healthy children with smallpox, that it could somehow prevent a full-blown case of the disease. He was variolated, i.e. “vaccinated,” with smallpox while at Wotton-under-Edge between Bristol and Gloucester, England. He suffered only a mild attack of smallpox, though for six weeks he was bled, purged, and then “haltered up” in the inoculation stables with other smallpox victims. Jenner first heard cowpox could prevent smallpox around age 13 when he was apprenticed as an apothecary. Local community immunity to smallpox depended on the local presence of cowpox—if there was no cowpox, then infection was more prevalent. Jenner understood the need for a vaccine for that reason. All this propelled him to find a better way to prevent smallpox. Chickenpox vs SmallpoxThis is chickenpox (varicella) before we had the chickenpox vaccine. In healthy children, the vesicles are very itchy and centrally located on the trunk, scalp, and face. The lesions may number from 250 to 500 blisters. Scarring is not uncommon because of the intense itching. In Jenner’s time, it was often confused for Variola minor, the less virulent form of smallpox. It’s hard to tell the difference clinically from the milder manifestation of smallpox. Don’t be fooled, though. Chickenpox can be terrible itself. Cerebellar ataxia (being wobbly and even unable to walk) occurs in about 1 in 4,000 children. Varicella encephalitis occurred in 1 in 50,000 to 1 in 33,000 cases. Adults with primary chickenpox are far sicker. Infection in pregnancy may leave the unborn child with permanent scarring, aplasia of extremities, chorioretinitis, micrognathia (small jaw), optic atrophy, cataracts, Horner syndrome (droopy eyelid), blindness, mental retardation, fetal herpes zoster and even death. Because parents were unaware of the significance of chicken pox, albeit in smaller numbers than smallpox, the chickenpox vaccine was easily discounted at first. They would even have chickenpox parties to get their kids infected and have it done with. Smallpox EradicatedIn late 1975, Rahima Banu, a three-year-old girl from Bangladesh, was the last person in the world to have naturally acquired variola major and the last person in Asia to have active smallpox. In 1977, in Somalia, Ali Maow Maalin was the last person to have naturally acquired smallpox caused by variola minor. On September 11, 1978, Janet Parker, a medical photographer at the Birmingham University Medical School in England, was the last person to die of smallpox, which was probably acquired from the nearby Medical Microbiology Department. In 1979, WHO recommended that all smallpox vaccination in the world cease and there was no more public vaccination beyond 1996. In 1980, smallpox was declared eradicated almost 200 years after Jenner’s discovery. Unlike many similar contagious scourges, we were able to eradicate smallpox because it has no animal reservoir outside of humans, and the vaccine was very effective. Could Smallpox Return?Unfortunately, the smallpox virus was not completely destroyed. Today, known smallpox virus exists in two places in the world; the CDC in Atlanta, Georgia, and the State Research Center of Virology and Biotechnology (VECTOR Institute) in Koltsovo, Russia. While these are high-level containment centers, we have to remember the story of Janet Parker, to understand that as long as smallpox is present anywhere, we are at risk. Smallpox scabs like the ones in this image were once used for variolation but were also collected for study. This is very problematic and poses some genuine risks even today. In 2014, the CDC reported workers clearing out a little-used cold-storage room belonging to the Food and Drug Administration found a cardboard box containing six sealed glass tubes labeled with the scientific name for smallpox, “variola.” Two of the tubes contained viable smallpox virus for the severe strain called variola major. Vaccination for smallpox reportedly is only good for about seven years, so the vast majority of the world today is susceptible. The official US statement is that presently there is enough vaccine to cover our population, but there is no proof of these supplies. What about the rest of the world? As long as smallpox exists in these two labs, or in some as yet hidden sample bottles of scabs, we are at risk. The coronavirus pandemic would pale in comparison should smallpox suddenly burst back onto the world stage. What Smallpox Taught UsOften vaccine opponents’ prime argument against immunization is that it weakens or destroys the immune system. There is simply no evidence for that. We already have an innate immune system response that can react to some infectious challenges with the first exposure. That is not true of smallpox. Only those who survived the infection developed immunity. Our immune systems have a memory for future challenges from an infectious agent and its antigens. That memory varies from a handful of years to a lifelong immunity. For most things, antigen exposure is our only real defense. Healthy immune systems thrive on antigen exposure. A few years ago, a study of three-year-olds with pica (eating dirt) showed they had healthier immune systems than children who didn’t because of antigen exposure. For that same reason, we don’t want antibiotics in our soaps since a sterile environment is actually bad for us. Why not use antibiotics instead of vaccines to treat all infections? Antibiotics only treat bacteria, and we have a lot of different medicines for that. The more we use them, the more the bacteria develop resistance. There are bacteria now that have become so resistant that there is no known treatment. We have only very few antiviral medications, and the two possible smallpox antivirals have never been tested in humans. Acquired ImmunityOur immune system thrives on antigen challenge! We need it to be healthy. Vaccines act like cowpox did for smallpox. They trigger a memory response without causing the disease of the infection itself. Some vaccine opponents want to delay vaccines, but there is no valid reason for this. Infections often have variable ages at which they cause disease. Vaccine schedules are specifically timed to prevent the infection for which they are indicated. Some opponents also want to pick and choose which vaccines they will give. That is problematic if a child is not protected against measles, though. Measles can cause the immune system to forget how to respond to infections for which it already has acquired a memory. That immune memory loss occurs regardless of whether immunity came from a previous infection or as a result of vaccination. This an immune amnesia can leave individuals with a lifelong sickly tendency. Acquired or adaptive immunity comes from antigen exposure and accounts for the vast bulk of our immune defenses. We are constantly exposed to infectious foreign antigens, probably in the hundreds of thousands in the first year of life alone. This is important beyond infectious agents, too. Recently, it has been shown that delaying solids and breastfeeding exclusively to 9 to 12 months significantly increases the risk of food allergies. (This video takes a deeper dive into the immune system—it will not be on the test.) PolioThe success with smallpox directed our attention to polio. These children are lying in a Drinker respirator, also known as an iron lung, because of paralytic polio. Polio spreads through fecal-oral contamination. It passes through the pharyngeal and intestinal mucosa. For around 72%, the infection doesn’t spread and symptoms can even be inapparent. About 24% have only minor symptoms such as fever, malaise, headache, nausea, vomiting, constipation, or sore throat. Non-paralytic polio causes an aseptic meningitis without paralysis, but only accounts for about 4% of infections and recovery in 2 to 10 days is rapid and complete. Paralytic polio accounts for under 1% of polio, but it is devastating. In children, it begins like the usual polio infections with typical symptoms of minor illness with a symptom-free period of 1 to 3 days. Adolescents and adults seem to skip the minor illness period and have more severe pain in the affected extremities. The virus then rapidly spreads to the spinal cord where it causes flaccid paralysis as it replicates and kills the nerve cells there. If polio spreads further to the brain, it is called bulbar poliomyelitis, which can weaken or even ablate the ability to breathe. The paralysis is lifelong as the nerve cells don’t regenerate. Paralysis and pain can worsen after 15 to 40 years beyond the acute infection, and this is called post-polio syndrome. Oddly, post-polio syndrome is more common in females for unknown reasons. Polio PandemiaLike smallpox, polio was known centuries back in history. The Egyptian stele from the 18th dynasty around 1400-1300 BC shows a man with a small, shrunken right leg in a position suggesting polio. This animation showing worldwide polio vaccination over time. Red means endemic and spreading widely. Yellow means polio free, but not certified by the WHO. Green means certified polio free. Once polio was confined to local endemic areas, but as the population and travel increased in the 19th and 20th centuries, it swept into epidemic proportions. Mortality rates soared with the epidemics; polio killed 27.1% of those infected in New York in 1916. Prior to vaccines, polio was the leading cause of of permanent disability in children. Two approaches to a vaccine were pursued initially. Jonas Salk developed an inactivated, dead injectable polio virus vaccine in 1955. Albert Sabin developed a live attenuated oral poliovirus vaccine in 1961. The live attenuated oral poliovirus quickly controlled polio in industrialized countries. The advantage of the attenuated oral polio vaccine is that the vaccinated individual spreads the virus to their contacts, who also become infected and immune. They then spread their attenuated poliovirus to their contacts. The disadvantage of this is that over time, the attenuated poliovirus can regain its virulence and itself produce and spread full-blown polio, called vaccine-associated paralytic polio. The inactivated injectable polio virus doesn’t cause polio and doesn’t spread person to person. For this reason, injectable polio vaccine has been the only polio vaccine used in the US since 2000. DiphtheriaIn contrast to smallpox and polio, diphtheria is still very much an infectious concern in the world. It is a bacterial illness spreads by droplet transmission to nasopharynx, larynx, and skin. A gray oropharyngeal membrane forms which can bleed and also become dislodged. Incubation is 1 to 5 days after infection. Cutaneous diphtheria toxin destroys flesh. Nasopharyngeal carriage is common. Fever is usually not higher than 38.5°C (101.3°F), and there can be a croup-like bark. Lymph nodes in the neck can become markedly enlarged, and edema there is called a “bullneck,” is a very serious sign. The gray pseudomembrane adheres firmly to the throat within a couple of days of infection and can slough off in pieces or as a whole. They can cause pneumonia or aspiration and suffocation. The treatment for diphtheria is directed both at the toxin and the bacteria. Diphtheria antitoxin known as toxoid. Routine vaccination with diphtheria toxoid is very effective at prevention. We use antibiotics in patients and in carriers. They do not improve healing of the local skin infection. https://www.storybookpeds.com/wp-content/uploads/2020/11/Diphtheria-and-the-Iditarod.m4a Diphtheria and SmallpoxDiphtheria and smallpox represent two different diseases, which pose similar risks because of large swaths of unvaccinated people. Until the late 1970s, billions of people worldwide received smallpox vaccine. Smallpox vaccination however is only good for about 7 years (maybe up to 10) before the immunity wanes. From 1983 through 2002, most US service members did not get vaccinated against smallpox. Between December 2002 and May 2014, more than 2.4 million service members were vaccinated for smallpox. Smallpox vaccine is still used routinely to protect a small number of people who work in the labs with the smallpox virus. About 95% of people are protected within 10 days after smallpox vaccination. Single dose vaccination provides substantial immunity while three doses protect for over thirty years—just the same as the yellow fever vaccine. If vaccination percentages fall and diphtheria again breaks out, there would be a substantial shift in vaccine acceptance. However, if smallpox were to break out with its 30% mortality rate, there would be mass panic to get vaccinated. Diphtheria vaccine is something we already have in adequate supply. Smallpox vaccine is however not available to the public. One source I found said there were enough doses of the smallpox vaccine in the US to treat “everyone who would need it.” “Everyone who would need it” was never defined, however. MeaslesMeasles is a highly contagious, paramyxovirus, of the genus Morbillivirus. The onset of symptoms is about 7 to 14 days after exposure and includes high fever, cough, runny nose known as coryza, red, watery conjunctivitis without crusting, a characteristic pharyngeal rash around day two, and a general macular to maculopapular rash around day four which often is associated with a temperature in the 104°F range. The pharyngeal rash develops with Koplik spots that are white, salt-like bumps within the wide area of inflammation. It only lasts for one to two days though, so it is often gone before clinicians could see it on exam. Infected individuals are contagious from up to 4 to 5 days before symptoms arise. What is the big deal today about measles? Measles ContagionWe characterize the contagion of a disease by its R0 (R naught) factor where a population has no immunity. It is a measure of how many people an index case is likely to infect. The Spanish flu that killed 50 million in 1917-1918 had an R0 of 1.4 to 2.8. The R0 for SARS-CoV-2 was first estimated to be 2 to 4, but it is closer to that of the flu. Measles on the other hand has an R0 of around 12 to 18. Contagion from one person is much more likely to others. But that is not the whole story. The virus can linger in the air for up to two or three hours after an infected person has left an exam room or waiting area. If thirty susceptible individuals are exposed in those areas during that time then 27 of them will become infected. Negative feelings about vaccines have led to significant drops in measles vaccination in recent years. Where there are pockets of groups of people who have little or no immunity, measles will run rampant. The high risk of measles contagion fuels a growing political movement against those refusing to vaccinate for measles in particular. Our personal rights are clashing against mandates suggesting the public good. The financial risk of contagion is pervasive. Medical office liability is a part of why you are seeing more and more offices refusing to accept unvaccinated children as patients. State governments like Georgia have moved to protect businesses from any customer liability in the SARS-CoV-2 pandemic for the same reason. Whooping CoughWhooping cough, or pertussis, is just as much a problem today as it was for me over thirty years ago when I started practice. To accurately diagnose it then and even today, a calcium alginate swab is inserted deep into the post-nasal area in an attempt to collect cuboidal epithelial cells mucous membranes. The swab is then rolled onto a glass slide where those cells will hopefully be transferred. It is then air dried and transported in a protective cardboard slide holder. The lab treats the slide a specific fluorescent antibody which lights up whooping cough bacteria stuck onto those epithelial cells under the microscope. Despite some newer blood tests, there is still not a better way to test for Pertussis in my opinion. Vaccination does not always imply immunity to Pertussis. Improvements in the vaccine of thirty years ago have made the pertussis vaccine and all other vaccines safe. Febrile reactions essentially vanished. Newer studies have shown that even in the rare case of febrile reactions and even febrile seizures that occur within the first day of any vaccination do not cause neurologic damage. An adult who has a cough last three weeks or so has a 21% chance of actually having pertussis, even if they were vaccinated as a child. Among children who are diagnosed with whooping cough, 35% of the time they were infected by their mothers. That is the reason you are seeing more and more obstetricians vaccinating expectant mothers during pregnancy. The optimal time for this is around 30 weeks gestation. The antibodies that she develops will be passed on across the placenta and her newborn will retain those pertussis antibodies for three or even four months. That is the most critical time to prevent whooping cough since the mortality is highest at that age. Many ERs, urgent cares, and physicians offices have shifted from Td (tetanus toxoid) to Tdap which includes acellurlar pertussis. That gives adults a pertussis booster which is important, since adults are the repository for the bacteria which infects children. National Vaccine Injury Compensation ProgramDespite these improvements and demonstrated vaccine safety, government vaccination mandates for public schools are why we have the National VICP (Vaccine Injury Compensation Program). This program is a no-fault claim resource that is important liability protection for medical providers. Without this program, each medical practice could (and would) be sued to the point that any and all medical care would cease due to the financial burden of defending such suits. Even physicians who oppose vaccination could be sued for injury related to infectious disease for which there was a prevention by non-vaxxing parents who later changed their minds. The VICP programs is not only the core reason why we can even have the choice to vaccinate or not, but the very foundation that pediatricians can really give care to children at all. Today, physicians have to also be concerned that they can be sued for disease occurrence due to NOT vaccinating children, even when parents have knowingly refused vaccines. That has fostered the move by many physicians to refuse to accept children whose parents refuse vaccines. It has to be understood that the VICP would NOT cover physicians in that case. I suspect this will become more and more the norm. Our feeling is that parents need to get all the information that we have so they can make a fully consicous decision and physicians can provide care reducing their risk of "wrongful disease," as you might call it. Other Childhood InfectionsWhen I started practice in 1986, I would see one or two cases of Hemophilus influenza type b meningitis a year. Since the vaccine came out and was required for public Georgia schools, I have seen no cases since 2000. Reactions to the H. flu vaccine are nil because of all we learned with Pertussis vaccine manufacture. The H. flu vaccine was first required in Georgia in 2000. Thirty-five years ago, 30% of ear infections were bacterial, and Streptococcus pneumoniae accounted for 30% of those. Ear infections were the bread and butter of pediatrics when I started, but not anymore since the newer vaccine for it. Pneumococcus is the prime cause of bacterial pneumonia and bacteremia. It accounted for about 20% or more of childhood fevers in my first practice but now only about 5% or less. The take-home about these vaccines is timing. Delaying these vaccines simply opens the window to the infection rates I used to see, because that is when children are most susceptible to these infections. Delaying vaccines don't have any effect on improved safety and would be analagous to trying to get liability insurance for your vehicle after you have already had the wreck. Mercury in VaccinesThimerasol, or thimersol, is a vaccine preservative that contains a very, very small amount of mercury. Multi-dose vaccine vials required a preservative to prevent bacterial contamination from repeated re-entry even with sterile injection needles. Today, almost all vaccines come in unit dose vials that don’t require this. The concern over mercury came from an illness called Minimata Disease. Minimata Bay in Japan is a vital source of fish which is a large part of the local population’s regular diet there. As industry around the bay proliferated the water became contaminated with local industrial mercury waste. Heavy metal neuropathy caused by mercury is a devastating neurologic illness in both children and adults, and was the cause of the outcry against Thimerasol. What most people don't understand is that there are two kinds of mercury; ethyl mercury and methyl mercury. Methyl mercury is what is present in industrial wastes and is the cause of Minimata disease. It has a half-life of 49 days and accumulates dramatically in fish exposed to these industrial waste. Thimerasol, which contains just over 49% mercury by weight, is metabolized to ethyl mercury and thiosalicylate. Ethyl mercury only has a half-life of 3 days. You would never inject thimerasol as shown in this image, but the quantity in each vial is miniscule. That means that mercury given now only in multi-dose vials presents absolutely no risk at all. Still opponents continue to bring up this issue. FormaldehydeFormaldehyde is used to attenuate vaccines that have a live virus constituent. Killing the virus and bacteria prevents infection and full blown disease. The NIH guidelines specify allowable formaldehyde residual in vaccines. For Diphtheria, levels cannot be more than 0.02% which equals 0.1mg per 0.5ml dose (with formaldehyde density of 0.815g/ml). The EPA sets standards for acceptable oral reference dose, or RfD, of formaldehyde. RfD is defined as “an estimate (with uncertainty spanning perhaps an order of magnitude) of a continuous inhalation exposure or a daily exposure to the human population (including sensitive subgroups) that is likely to be without an appreciable risk of deleterious noncancer effects during a lifetime.” The RfD for formaldehyde (oral administration) is 0.2 mg/kg of bodyweight per day. For a 22 pound (or 10 kg) child, that calculates to an acceptable level of exposure at or below 2 mg daily for a prolonged period. Comparatively, vaccine formaldehyde for the entire first year of recommended vaccines is well below the daily acceptable EPA exposure levels. Further to this, formaldehyde is naturally present in our own body as a result of normal biochemical processes. Our body contains around 2.6 mg/L of formaldehyde. A 22 pound (10 kg) child is around 65% to 75% water which means their body consists of 6.5 kg of water. Because water is 1ml/gm, that means this child has 6.5 liters of water in their body. That means they have as a baseline 16.9 mg of formaldehyde at all times. Any vaccine dose containing 0.1mg of formaldehyde has 169 times less formaldehyde than is already present in their body. Additionally we must consider what ways are we exposed to formaldehyde in our daily lives especially in the furniture in our homes. AluminumAluminum is valuable in non-live vaccines because it is an adjuvant, which means it boosts the immune response of vaccines. Adjuvants reduce the amount of vaccine required to produce immunogenic response. Adults consume about 7 to 9 mg of aluminum a day. In the first six months of life, non-soy formula-fed babies consume about 38 mg. Breastfed infants get 7 mg in the first six months. Babies fed soy formula get 117 mg. By comparison, infants get about 4.4 mg of aluminum in their regular vaccines in the first six months, albeit through injection rather than ingestion. Aluminum is the most abundant metal constituting 8% of the earth’s crust. We are all exposed to aluminum all day every day. If you eliminated aluminum from vaccines, you wouldn’t reduce the total daily exposure by any degree. Aluminum toxicity is therefore also a non-issue in vaccines while being giving the take rates at lower injection doses a boost. Vaccine opponents usually reach for aluminum as a last ditch effort to sway public opinion. Vaccine GroupingA common concern is that there are so many things now in one vaccine which surely must be harmful. Mistakenly thinking it is safer, parents often ask me to do an altered schedule to spread vaccines out instead of grouping them according the published guidelines. It has been shown that grouping immunizations improves the immunogenic take rate for each individual vaccine. Tdap is one such combination vaccine that I hope will completely replace the Td because it also has acellular pertussis in it. If mothers are vaccinated with Tdap prior to pregnancy then the transplacental antibodies give passive immunity for pertussis (whooping cough) to their babies for the first three or four months. We also use Td to prevent lockjaw when someone gets a puncture with a rusty nail. In one study that I read a few years ago, if an adult has a persistent cough for two to three weeks, the probability that pertussis was the source was around 21%. Because the repository of pertussis is in the adult population, by switching entirely form Td to Tdap, every time someone gets a Tetanus shot, we boost their immunity to pertussis and lower the risk to children. MMR & AutismWakefield’s original study claiming that MMR was the cause of autism included just 12 children. Initially it made me cringe when it was first published because I knew the value of vaccines. This claim had to be seriously considered because it alleged specifically that a serious medical illness in children was caused by vaccination. While the Lancet, in 2010, declared Andrew Wakefield’s original 1998 study a fraud, the damage was done. Wakefield profited greatly from the litigation where as an expert witness he based everything on his own article. Wakefield had also filed a UK patent application for his own vaccine/therapeutic agent for measles and inflammatory bowel disease in June 1997, several months before he published his MMR/autism article. He was kicked out of Britain and practiced in Austin, Texas for about a year before getting out of medicine altogether so I last heard. He continues to fuel the anti vaccine movement even today despite being discredited. It is primarily because of this article that I spend so much time on vaccine education. We had better remember Welch and his outbreak of diphtheria. We need to keep in mind that Smallpox virus still exists in known and unknown places in the world and it may not be “if” but “when” it sneaks out of hiding. 1. Fetal Tissue and VaccinesThe most serious claim that vaccine opponents make is that the injected materials contain aborted fetal material. This is not true, but few know or understand how this claim came to be. It started with the polio vaccines. The Salk Polio injectable vaccine came from inactivated, or killed, polio virus. The Sabin Polio oral polio vaccine was manufactured from attenuated, or live, polio virus which had been treated with formaldehyde. The “Cutter Incident” refers to the first manufacture of the Salk version of the polio vaccine where the filters allowed some of the virus to “hide” from the formaldehyde and thus remain viable and virulent. There were children that were affected with polio. The “Cutter Incident” initiated the first government oversight of all vaccine manufacture, and was part of the reason the National Childhood Vaccine Injury Act was passed in 1986. It created the National Vaccine Injury Compensation Program (VICP), a no-fault route for children or adults pursuing reimbursement for vaccine injury claims. It is government trust fund financed by an excise tax on all vaccines. The goal was to reduce the time for patients and their families to receive compensation through usual legal channels. 2. Fetal Tissue and VaccinesViral vaccine manufacture requires a continuing supply of the target virus which, unlike bacteria, do not grow outside of a host cell. The virus must take over the host cell biochemical machinery just as it would in the wild. The host cell is not included in any vaccine material. Only the virus is used to make the vaccine. Originally monkey cell strains were used to create these viral stocks. It was discovered however that SV40 (Simian Virus 40) which did not cause disease in humans was discovered in some of these monkey host cells. As a result, the FDA decided that no human vaccines could be made using non-human cell strains. The terms cell line and cell strains are different. Cell lines are immortalized in that they can continue to replicate indefinitely. The most famous is the HeLa cell line which came from cervical cancer cells of Henrietta Lacks who passed away from her disease, and who by the way never gave her permission for their use. It is because they are mutated cancer cells that these cell lines never die. The FDA has also refused to allow vaccines where the virus supply comes from such cells. The proof of effectiveness had already been shown before the monkey virus was found. With these limitations, a new source of human diploid cells had to be found. These cells would not replicate forever however like a cell line. 3. Fetal Tissue and VaccinesHumans and all animals constantly shed normal cells, mostly from skin. These shed cells, however, will not grow virus. In 1961, Dr. Hayflick, working at the Wistar Institute on the campus of the University of Pennsylvania in Philadelphia, developed the WI-38 cell strain which could replicate poliovirus. Philadelphia was also experiencing a polio epidemic. The source of the original WI-38 cell strain came from a fetal lung tissue cell. That is the reason some people object to vaccines, even though none of them contain fetal cells or fetal material. Abortion was illegal in the United States at that time, so fetal tissue was provided by Dr. Sven Gard of the Karolinska Institute Medical School in Stockholm, Sweden. A family in Sweden, who felt they already had too many children, had sadly chosen to abort. Both parents were alive and well and married to each other. Dr. Gard chose their unborn child because it had no history of familial disease or cancer. I cannot say how profoundly emotional it is for me thinking about this child. But it is certain that these parents had already chosen abortion for no reason related to any interest in their baby’s tissues. While the cell strain came from one cell of that one aborted fetus, vaccines do not contain any aborted fetal tissue material no matter what opponents try to say. 4. Fetal Tissue and VaccinesNeither I nor my colleagues or Storybook Pediatrics as a practice endorse abortion, nor would we use use vaccines that contained material from any abortions. While we decry that baby’s parents’ decision, we have mixed emotions. It makes me think about a heart transplant where someone besides the donor makes all the decisions. How many people die naturally or unnaturally, do so without donating tissues or cells that could help someone living. That baby’s life mattered, and I will always remember how many people’s lives were saved as a result. Researchers have estimated vaccines made from virus which was cultivated in WI-38 secondary cell strains have prevented nearly 11 million deaths and prevented (or treated, in the example of rabies) 4.5 billion cases of disease. Unlike abnormal cancer cells, the WI-38 strain cultures are nearing the end of their ability to replicate. My thought is that future technology will use non-fetal stem cells to provide new cell strains. We have that technology I believe. Today these vaccines are the ones I know that use human diploid (normal) cell strains for virus production. • Hepatitis A vaccines [VAQTA/Merck, Havrix/GlaxoSmithKline, and part of Twinrix/GlaxoSmithKline] • Rubella vaccine [MERUVAX II/Merck, part of MMR II/Merck, and ProQuad/Merck] • Varicella (chickenpox) vaccine [Varivax/Merck, and part of ProQuad/Merck] • Zoster (shingles) vaccine [Zostavax/Merck] • Adenovirus Type 4 and Type 7 oral vaccine [Barr Labs] * • Rabies vaccine [IMOVAX/Sanofi Pasteur] * 1. Historical Trends in VaccinationThe graph shows the typical progression of disease with a vaccine that shows historically the public response over time. Farwick Collinsworth and his family owned a large portion of the small Texas town. When the epidemic came, the illness took his 11-year-old granddaughter first. Next, it claimed the lives of his wife and two sons. Following them, two more grandchildren and a nephew died from the viral disease. Around the time the small, 45-year-old Texas town was founded, the vaccine had already been available for over forty years. The widespread outbreak continued. Four years later, in March, a riot would occur in another relatively nearby Texas town protesting a quarantine and vaccination order for the disease. The Texas governor sent the Texas Rangers led by Captain J. H. Rogers to enforce the health officials’ vaccination order more vigorously than some city’s residents thought proper. Milling protestors pelted the rangers and health care workers with harsh words and hard rocks, causing minor injuries. The next day when Captain Rogers got word someone had telephoned a local hardware store to order 2,000 rounds of buckshot, he ordered his men to begin a house-to-house search of the area of town where the order had originated. The situation deteriorated into a riot, and after it was over, the Rangers had killed two citizens and wounded 10 others. It wasn’t until the cavalry from nearby Fort Mcintosh arrived that order was restored, and the inoculation and fumigation program continued. The quarantine and vaccination program that began in March 1 finally ended on May 1. That first city was Plano, Texas. The protests in the second city are known as the Laredo Smallpox Riot. 2. Historical Trends in VaccinationThis sounds all too familiar with the mood in the US today. Staunch vaccine advocates and Anti-vaccine groups are becoming increasingly angry at one another. Physicians and various others in health care are increasingly divided as well. Many practices are now refusing to accept Pediatric patients if they aren’t fully vaccinated. Conversely, a few practices even have physicians recommending delayed schedules or opposing them altogether. There is possibly a potentially big clash coming. How are we to prevent a repeat of the history of Laredo and Plano? Above all, we must understand that while vaccine issues seem large, the implications of loss of liberty and freedom using the guise of the good of the public looms large. What other freedoms do we currently enjoy that might end up on the government chopping block for the “good of all?” It seems certain considering recent measles and SARS-CoV-2 outbreaks, that if we ostracize anti-vaccine parents and patients, we are going to have government impose the will of those staunchly in favor of vaccines, as they did in Laredo, Texas. We cannot condone those physicians who give carte blanche anti-vaccine recommendations to patients. It is terrifying to me that state government could begin pulling the licenses of those physicians. And if they do, what other areas such as the care of the aged and dying, or chronically ill or disabled, will be next? The ramifications for government mandated medicine, let alone socialized medicine, are awful.