Shots in the DARK?

Debate over new generation of vaccines gets prickly.

Do we really need a vaccine for chicken pox? Local and national health gurus think so. Here's why: parents shouldn't have to miss several days of work to stay home with their sick kids.

"It's more of a convenience thing," explains Rita Schmidt, maternal and child health program director of the Washington state Health Department, which early this year told pediatricians they must make the chicken pox vaccine available to patients.

It's an odd message to encode in public policy—almost a parody of the values that working moms are seen to have by their critics. Maybe we could inoculate kids against crying, too, so we'd never lose valuable work time comforting them.

But it underscores the shaky ground beneath the medical field as it contemplates a new generation of vaccines aimed at either relatively benign or uncommon diseases, a generation in its infancy. "There's been an explosion in what we understand about molecular biology," says UW pediatrics professor Dr. Edgar Marcuse. Consequently, he says there will soon be an "explosion" in the number of available vaccines.

Medically speaking, these vaccines are not the "no-brainers" that their predecessors were, as Dr. Jim Taylor, director of UW Medical Center's Pediatric Center, puts it. And so more and more, he predicts, we'll be hearing the work-loss argument. (Not the best marketing strategy, notes Taylor, who found it played poorly among Washington state parents he recently surveyed.)

If there is ambivalence in the mainstream medical community toward the new vaccines, there is downright hostility among others: alternative medicine enthusiasts who believe in the supremacy of natural immunity; conservatives who bristle at the way public health regulations restrict individual choice; and parents whose children serve as a heart-breaking reminder that vaccines are not risk-free.

Congress has even taken up the matter. In May, Republican US Rep. John Mica held a hearing on the hepatitis B vaccine, certainly a more severe illness than chicken pox but one that is most prevalent among gays, drug users, and immigrants from Third World countries.

In a way, the controversy over vaccines is nothing new. Doses of organisms that look enough like a disease to stimulate the body's immune system, vaccines have always generated suspicion. Back in the 1800s, there was even a ruckus over the smallpox vaccine, now the most hallowed of them all.

But the use of vaccines for less urgent threats to the general populace has broadened the anti-vaccine movement, once confined to the New Age fringe. And it heats up the question of whether the risks of immunization outweigh the benefits.

The controversy carries high stakes. State health departments have the power to mandate universal vaccination by requiring that children be immunized before being allowed into school. Although it's not widely known, parents in this state can opt out by citing medical, religious, or philosophical objections.

Doctors tend to view vaccines with awe because they are in a position to know what difference they make. "When I was in training as a resident at Children's Hospital, I took care of haemophilus meningitis every single night," reminisces Dr. Rich Kovar, medical director of the Capitol Hillbased Country Doctor Community Health Centers. "One half of those kids were chronically disabled. The meningitis vaccine came out in the mid-'80s, and I haven't seen a case in years."

Vaccines, of course, have also eradicated smallpox and nearly wiped out polio. "They are one of the few things we do in medicine that we know without a shadow of a doubt is effective," says the UW's Taylor.

So it's worth paying attention when doctors fall off the immunization bandwagon. As of two years ago, less than half of the state's pediatricians routinely used the chicken pox vaccine, according to another recent survey by Taylor.

Undoubtedly like many doctors, Kovar feels that the dangers from chicken pox are real but very small. Every year in this country, some 10,000 people are hospitalized and 100 people die as a result of the disease, which strikes four million people a year.

"If you're a public health person, you say, let's just give the vaccine to everyone. We can prevent some deaths," Kovar says. "The problem for me is more pragmatic— how not to freak parents out at the whole vaccine pile." Already, school entry requirements in this state call for 15 to 16 doses of six vaccines: diphtheria and tetanus; pertussis (whooping cough); polio; measles, mumps, and rubella; haemophilus influenzae B (which causes meningitis); and hepatitis B.

Taylor, for his part, says he was initially "wishy-washy" about the chicken pox vaccine in part because of questions over whether the immunity generated would be lifelong. But in an example of how immunization programs are self-perpetuating, Taylor figured that "once we get going we might as well go ahead and do it." Doing it halfway, alternatively, would mean less chicken pox at large, so that the unvaccinated might not catch it until they were adults, when the disease is more dangerous

Still, doctors generally don't question whether vaccines are lethal in themselves. "We do all this hand-wringing," Taylor says, "but pretty much vaccines are getting way better."

Anti-vaccine groups, on the other hand, do ask just that question. Their concern of the moment is the hepatitis B vaccine, which they link to everything from seizures to multiple sclerosis. They cite thousands of "adverse" reactions to the hepatitis B vaccine reported to the federal Centers for Disease Control.

But the CDC tracks reports by parents and others who believe that a vaccine has caused health problems, not proven cases. For that reason, it's hard to get a handle on just how great a risk vaccines pose, unless you trust drug company studies. Academia does tackle the subject with long-term studies, but often not before health authorities have jumped on board an immunization program.

Clearly, however, there is some risk to every vaccine. Consider: the only cases of polio now in this country are the eight to 10 cases a year of "vaccine polio."

And if you're a parent, statistics and studies don't necessarily matter. Take the case of Michael Belkin of New York, who testified at Congress' hearing on the hepatitis B vaccine. Belkin's five-week-old daughter Lila died 15 hours after receiving her second hepatitis B shot. Before that, she was never ill. "At her final feeding," he testified, "she was extremely agitated, noisy, and feisty, and then she fell asleep suddenly and stopped breathing." A medical examiner ruled that her death was due to Sudden Infant Death Syndrome, the catchall diagnosis for the inexplicable.

If you were Belkin, would you let a second child get the vaccine?

Anti-vaccine activists also believe that there is a cumulative effect to the many vaccines children now receive. They suggestively note unexplained increases in such afflictions as asthma and Attention Deficit Disorder. The evidence is nonexistent. They have a point, however, when they emphasize what a radical new approach the current extensive immunization schedule represents. "We're going from a generation, my parents' generation, that got one vaccine—smallpox," says Barbara Loe Fisher, president of the nonprofit National Vaccine Information Center in Washington, DC. "We have to take a step back and say, what are we really doing to the immune system?"

Moreover, as even more vaccines loom, there is something of a philosophical question in the air about society's tolerance for disease. "Some of the illnesses that used to be part of everybody's growing up don't have to be," says Marcuse of the UW, defending immunization for vaccines that "just make you sick" as opposed to killing you.

But others wonder whether we should go after every disease simply because we can. "The question is not whether there should be a few vaccines for very serious diseases," says Fisher. "The question is whether we have gone way overboard in saying that there should be no disease, that man is supposed to be disease-free."

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