Vaccines: An Interview with Dr. Paul Offit

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Vaccines have been one of the greatest public health achievements of the modern era. Yet, vaccination rates are dropping as parents fear the risks of vaccination more than the diseases that vaccines prevent.

Dr. Paul Offit is the Chief of the Division of Infectious Diseases and the Director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and the Maurice R. Hilleman Professor of Vaccinology at the University of Pennsylvania School of Medicine.

He is also the author of a new book on vaccines, the anti-vaccine movement, and the fear that governs many of the choices surrounding vaccinations.

I spoke to Dr. Offit on the phone from his home near Philadelphia.

David: At times when reading Deadly Choices, I felt there were two different stories being told. In the first, vaccination rates are dropping and society is at an increased risk of an epidemic. In the second, several new vaccines have been produced over the last 20 or 30 years, and we’ve seen another round of diseases drop away from everyday risk. How do you square these two contrasting narratives?

Dr. Offit: I think that we ask a lot of the American public, more so than any other country. When you’re asking the American public to vaccinate their children with vaccines to prevent 14 different diseases by the age of five, 16 different diseases by adolescence, which can mean as many as 26 shots in the first years of life and five shots at one time, that is a lot to ask especially when you don’t see most of these diseases. So vaccination is a matter of faith.

I think you can look on balance at the United States in general and you see very high immunization rates, meaning immunization rates in the high 80%, low 90% range and consequent to that a dramatic reduction in the instance of these diseases. What’s happened, however, is that in certain communities or areas, you are starting to see an erosion in vaccine rates. That has caused the outbreaks that you see. Measles in Southern California, mumps in New York and New Jersey, or mumps in the Midwest, whooping cough in California to a level we hadn’t seen since 1947. When you see that, you do see at least a fraying of the edges and worry that that fraying could become much worse.

When you hear Jenny McCarthy say, “I’ll take the freaking measles every time,” she has no idea what measles is — which tells you in some ways how remarkably successful the vaccine programs have been.

David: Do you see any silver lining to the anti-vaccine movement? The possibility that this has led to ultra-vigilant safety measures, that when considered in the long term may prove beneficial to public health and public confidence in vaccines?

Dr. Offit: I certainly think there is a role for consumerism in vaccines. The example that I would use would be someone like John Salamone. Here’s a man whose child suffered paralysis, permanent paralysis from the oral polio vaccine. He formed a group called Informed Parents against Vaccines. I’m sorry, he formed a group called Informed Parents Against Vaccine-Associated Paralytic Polio, IPAV. He would go to the CDC meetings. He would go to the American Academy of Pediatrics meetings and he would lobby for the fact that this vaccine had a very rare but very real side effect and that side effect affected his child.

He had everything to do, frankly, with our move in 1998 from a vaccine schedule that included the oral polio vaccine to one that didn’t. So now we use the inactivated polio vaccine because there was safer alternative. Do I think that there’s a role for consumerism in vaccines? Absolutely, but it always has to be science based. When you look at the current anti-vaccine movement – the claims are things like vaccines cause autism or diabetes or multiple sclerosis or autoimmune diseases or diseases that clearly aren’t caused by vaccines and have been shown to be not caused by vaccines and that movement continues to make the case that, yes, they do and we don’t believe you, I don’t think there is anything good that comes of that.

I think that, right now, the system in place to monitor, to test vaccines before licensure, and to monitor vaccines after licensure is excellent. I think that the sort of ranting by the anti-vaccine people that vaccines are causing autism when they are not has done no good.

David: It’s one of the hardest things to explain to people why anecdotal evidence doesn’t have much significance in matters of science and medicine. Yes, it can raise some interesting questions. Yes, it can be a starting point to inquiry and research, but it doesn’t determine – it can’t determine  – what works and what doesn’t, what is harmful and what isn’t. Do you have any good analogies for explaining why clinical studies trump anecdote and personal experience? How do you personally explain this to someone without any scientific background?

Dr. Offit: I only wish that it were true that scientific studies trump anecdote. It’s very hard for scientific studies, at least in the minds of many parents, to trump anecdote because anecdotes are so powerful, emotional, and personal. It’s very hard to trump that with statistics.

The example that I use is an example which happened to my wife. She came into the office on a weekend day. She was helping the nurse give vaccines. She walked into a room. A mother was sitting with her four month old child waiting alongside of the wall. While my wife was drawing the vaccine through the syringe, the child had a seizure and went on to have the permanent seizure disorder, epilepsy. If my wife had given that vaccine five minutes earlier, I think there are no amount of statistical data in the world that would’ve convinced that mother of anything other than the vaccine caused it. What else could it have been, right? I mean, the child was fine, they got this vaccine, and then they had epilepsy. What else could it have been? Even though, in that particular case, my wife hadn’t given the vaccine yet.

So it’s very hard to use statistics to trump that. But it’s all you have. If someone asks the question, it’s a reasonable question. My child was fine, they got the measles-mumps-rubella vaccine, now they have signs and symptoms of autism. Could the vaccine have done it? I think that’s a fair question. The good news is it’s an answerable question. Now we have about 14 studies that have been now looking at hundreds of thousands of people who did or didn’t get that vaccine. We know that risk is no greater in the vaccinated group. I think you just have to try and explain that to people. It’s not easy.

When I was a resident of a hospital in Pittsburgh, there was a five year old boy who had leukemia. The mother was convinced that in the previous month he had for the first time started to eat peanut butter sandwiches, and she wondered whether those peanut butter sandwiches could have caused his leukemia. I mean, it’s a fair question. You could imagine something. You could say the aflatoxin, which is a toxin contained in trace amounts of peanuts and therefore likely in peanut butter, we know can damage the liver. Maybe you could argue that it could also damage bone marrow and cause leukemia. I don’t think there has ever been a study looking at the relationship between peanut butter sandwiches and leukemia, but that’s doable. You can do that study. So I guess you just have to try and explain what the scientific method is, how it works, how it can answer questions parents have. And then hopefully, when the answers come, they’ll be believed.

David: I think one of the factors that makes the anti-vaccine movement so powerful is that it crosses several typical sociopolitical lines. You’ve got anti-government conservatives mixed with new age liberals. The crude and decidedly low-brow Jenny McCarthy sharing talking points with Bill Maher, who usually appeals to a fairly well-educated crowd. Does this make them more difficult to discredit?

Dr. Offit: It’s remarkable, isn’t it? You have, I remember seeing a Larry King episode and this sort of gets to the heart of the question. Larry King had on — not that anyone should look to Larry King for health care advice — but on this particular episode you had Jenny McCarthy, you had Holly Robinson-Peete, both mothers of children with autism. Then you had a non celebrity mother of a child with autism. His show is to examine autism and its causes, its treatments. He seriously looked at every one of those three parents and said, “What do you think causes autism?”

You’re watching this show and you’re thinking, why don’t you have an autism expert on the show? I mean, someone who has devoted their research and their life to understanding the disorder, who has generated papers that have been published in scientific journals, to answer those kinds of questions. Certainly, with autism, there are starting to be some answers that are interesting. Why is it that one believes that if a parent has a child with a particular disorder, that that makes them an expert on that disorder, when they haven’t studied it? They’re an expert only on their own child. So it’s illogical and it’s surprising.

You’re right. If you look at who it is that questions vaccines, it tends to be a well-educated, upper class group. I just would think if you listen to Jenny McCarthy and the way that she formulates her arguments and the way that she constructs her logic, you couldn’t fail to not be impressed by her. Yet, people are influenced. I don’t know why. Maybe it’s because you see her on the big screen. I haven’t seen her much on the big screen, but I mean she was in “John Tucker Must Die” and maybe that’s just enough for you to believe that you think you know her better than the scientists who are going to be on the show. I don’t know. It’s painful, though.

David: Some of the numbers you offer in the book are really shocking: 7,000 deaths per year from whooping cough in the 1940s; hundreds of deaths from measles; 70 annual deaths from chicken pox. Many of these diseases are considered rites of passage for young kids, but in truth they used to cost many kids their lives. These aren’t trivial diseases to be dismissed, are they?

Dr. Offit: No, unless you’re talking about passages to heaven, there is no rite of passage with many vaccine preventable diseases. Measles actually would kill thousands of children a year, between 3,000 and 5,000. Mumps was a common cause of deafness. Certainly rubella, German measles caused 20,000 cases every year of permanent birth defects. I mean, I think for my parents who saw these diseases vaccines were an easy sell. I was a child of the ’50s. For me, vaccines were an easy sell. I think people don’t believe it. I think that when you hear Jenny McCarthy say, “I’ll take the freaking measles every time,” she has no idea what measles is, which tells you in some ways how remarkably successful the vaccine programs have been, but in other ways how little we appreciate it.

David: Where would you place vaccines in the pecking order of advancements that moved life expectancy ahead so far in the 20th century?

Dr. Offit: Certainly in 1900, if you compare the length of time that we lived in the 1900s compared to our longevity today, we have increased our longevity by about 30 years. What has contributed to that? I think probably the number one thing is purification of the drinking water, meaning to get an adequate separation of sewage from potable water. I would put vaccines second. I think if you look at when vaccines get introduced into certain developing world countries, the lifespan increases dramatically. The child mortality rate decreases dramatically. So vaccines I would put at number two.

David: For several years now, Dr. John Ioannidis has been making the case that medicine isn’t nearly as well founded on good science as we’re led to believe —as many doctors do believe. More recently, a study by two Johns Hopkins doctors found that previously conducted studies are rarely cited by later rounds of inquiry on the same subject, calling into question the entire framework on which biomedical science resides. What makes you think that vaccines lie outside of these issues, that we can and should have so much confidence in their safety and effectiveness?

Dr. Offit: I think vaccines, I would argue, in the world of evidence based medicine have the most consistent evidence base of arguably anything that we have evidence for. In order to get a vaccine licensed, you have to do prospective, placebo controlled studies on thousands and now tens of thousands of children. No other medical product, certainly not drugs, ever goes through that extensive level of testing. Also, once a vaccine is licensed, it is subject to post-licensure monitoring by things like the Vaccine Safety Datalink, which is unmatched in drugs. If there’s a problem, it’s very quickly picked up and the vaccine is taken from the market, which was the RotaShield story in 1998.

Vaccines sit on a very, very solid base and have stood the test of time since our first vaccine 200 years ago —the smallpox vaccine. You’ve probably never seen smallpox, I’ve never seen smallpox, but smallpox has probably killed more people in our world’s history than any other infectious disease. We will never see it again, probably, because of vaccines. I think in terms of an evidence base, you just can’t beat vaccines.

David: Perhaps the most disturbing thing about the anti-vaccine movement is that they ignore all of the real risks and deficiencies of vaccines. For example, the oral polio vaccine that was unnecessarily passing the disease onto approximately 15 kids every year in the early 1980’s – this didn’t seem to interest the anti-vaccine protesters did it?

Dr. Offit: No. So there are problems with vaccines — like any medical product — it has positive effects, it can have a negative effect. Vaccines are no different. By constantly focusing, however, on problems that aren’t associated with vaccines, like autism, diabetes, and Multiple Sclerosis — I just don’t think anything good is coming of that. I think vaccine advocacy has a role but nothing good comes from focusing on these things that are not science based. It’s too bad.

The thing that amazes me. Andrew Wakefield, for example, published an article in the Lancet. Now, to say that study is flawed is an understatement. It really wasn’t a study, it was a case series. And now we know there were a number of fraudulent activities and misrepresentations associated with that case series.

And yet, those who oppose vaccines still revere Andrew Wakefield. What does that say, it’s almost as if, he’s become a counter-cultural hero. Because he’s basically seen as speaking truth to power. Speaking truth to the man. When all he’s done is prevented people from getting a vaccine that could have save their lives. 3 people dying in Ireland. 1 person in England, because the parent was more frightened of the vaccine than the disease their child died from.

David: As a society we spend a lot of money on healthcare. And much of that on treatments, supplements and procedures that do very little to help people live longer or healthier lives. Can you think of any investment we’ve made as a society that has a better return on the dollar than vaccines?

Dr. Offit: No. No I can’t. It’s a great question. You put your finger right on it, — what do we spend our money on? Part of it is what used to be called unconventional or fringe medicine. It’s now called — much more euphemistically — alternative or complimentary medicine. So what have we gotten from that? It’s an $80 billion pharmaceutical industry that tells us that taking more vitamins, or minerals, or supplements and these quote unquote, natural herb products are a value to us. One — where’s the evidence? There is none. And two — what have we gotten for all that money? I think you’re right, for all the money we spend — in theory trying to improve our health — we could no doubt spend it better.

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