Vaccines and Epidemics
Jane M. Orient, MD
It has been said that every epidemic begins with a single case report. A single case report, however, could just be an anecdote, and most "clusters" turn out to be statistical artifacts.
One can make two types of errors: Type A --- overreacting to a false alarm like Chicken Little; and Type B --- ignoring a sentinel event and behaving like an ostrich.
To limit the mortality and morbidity if there really is an epidemic, we must investigate case reports dispassionately, following the evidence wherever it leads --- even if we must dare to question some sacred cows.
Two syndromes devastating to children are discussed in this issue: Shaken Baby Syndrome (SBS), which is being treated as an epidemic, and autism, in which a four-fold increase is treated as a mere change in diagnostic criteria. (The increase could be ten-fold or more in some areas, according to a review by the father of an afflicted child, which is published on the Internet.)(1)
Parents (and grandparents and au pairs) have, for some reason, apparently developed an inclination to shake their babies violently. From 1,000 to 1,400 babies per year are claimed to die in the United States from forceful shaking,(2) although the National Center for Injury Prevention and Control (NCIPC) estimates only 1,895 deaths in children less than one year old from injuries of all types.(3) Many hospitals are asking new parents to sign an affidavit saying that they understand the risk after viewing a video on SBS.(2)
Numerous parents have been accused of murdering their babies, and not all have been as fortunate as Louise Woodward. Alan Yurko, the father who inspired Dr. Buttram's article,(4) is serving life plus ten years without possibility of parole in a Florida prison. Police are on the alert. Upon arrival at the scene, as in a case of Sudden Infant Death Syndrome (SIDS), they may immediately try to extract a confession: "When you noticed that he wasn't breathing, that's when you shook him, right?"
Subdural hematomas have possibly become more common in babies; Buttram discusses the differential diagnosis. If nonaccidental trauma is not the problem, affidavits and prisons are not the solution.
With autism, a "secular trend in numbers of cases enrolled in California's regional service center system" --- an "occurrence," not an epidemic --- has been observed. Between 1980 and 1994, there was a 373 percent increase in autism rates, from 44 to 208 cases per 100,000 live births.(5) The latter figure would extrapolate to nearly 8,000 new cases nationwide per year.
What happened between 1960 or 1970 and 1980? The pediatrics textbook we used in medical school contains only two lines referring to autism: an allusion to the syndrome as a consequence of congenital rubella and a mention of autistic posturing in the rumination syndrome.(6) A MedLine search found 175 articles on "Autistic Disorder" or "autism.mp" between 1960 and 1968, the year the rubella vaccine was licensed (an average of 19 per year); 250 between 1969 and 1971, the year the MMR vaccine was licensed (83 per year); 5023 between 1960 and mid-1998 (118 per year); and 918 between mid-1998 and mid-2001 (306 per year). This is a crude surrogate for reliable incidence figures, which are lacking; the California Department of Developmental Services specifically disclaims that its case numbers represent actual incidence.(5) Neither this study nor the British study often cited as "disproving" the MMR-autism connection(7) gives any statistics prior to 1979.
A possible association between autism and viral illnesses and/or immune problems is hardly a new or implausible suggestion. A 1976 article, which stated that "autism has been associated with a number of diseases, including prenatal rubella," found that 5 of 13 autistic children had undetectable antibody titers after rubella vaccine, whereas all 8 normal children had detectable titers. The author concluded that autistic children may have an "altered immune response."(8) Certainly, the possibility that live vaccines might produce complications similar to those of the wild disease --- especially in patients with abnormal immune systems --- cannot be lightly dismissed. Yet a temporal link between a vaccine and regressive autism is called a "possible rare occurrence," and the "anecdotal reports" from parents are "unlucky coincidences."(9)
How many unlucky coincidences make an epidemic? The proper question to ask is whether there is a statistically significant increase in autism in vaccinated children compared with unvaccinated children. But if relevant data exist, as Taylor's paper hints,(7) they are inaccessible. (Taylor refused to make his data available either to me or to Congressman Dan Burton's committee.) The California study was an ecological one; it could not link immunization with autism records.(5)
The autism cases presented in this issue by Yakbak and Lang-Radosh are not mere disconnected anecdotes, as they show a very disturbing pattern.(10) Although the method of ascertainment is admittedly biased, the absolute number of cases and their severity demonstrate a clear need for active long-term surveillance after postpartum vaccines. Case-control studies of children with autism spectral disorders should examine the immunization history of both the children and their mothers. It is possible that the mothers' history holds a key to the autism puzzle.
In our zeal to prevent childhood diseases, are we overlooking or even suppressing evidence of terrible iatrogenic complications of vaccines --- and, worse, scapegoating the victims? Will future generations study our times in the same light as the era of witch trials, or the age of denial of the importance of hygiene?
1.# Thrower D. MMR and late-onset autism (autistic enterocolitis) ---
a briefing note. www.whale.to/vaccine/thrower11.html.
2. Foderaro L. A simple video finds success against shaken baby abuse. New York Times, May 29, 2001.
4. Buttram HE. Shaken Baby Syndrome --- or Vaccine-Induced Encephalitis? Medical Sentinel 2001;6(3):83-89.
5. Dales L, Hammer SJ, Smith NJ. Time trends in autism and in MMR immunization coverage in California. JAMA 2001;285:1183-1185.
6. Barnett HL, ed. Pediatrics, ed 15. Appleton-Century-Crofts, New York, 1972.
7. Taylor B, Miller E, Farrington CP, et al. Autism and measles, mumps, rubella vaccine: no epidemiological evidence for a causal association. Lancet 1999;353:2026-2029.
8. Stubbs EG. Autistic children exhibit undetectable hemagglutination-inhibition antibody titers despite previous rubella vaccination. J Autism and Childhood Schizophrenia 1976;6:269-274.
9. Vastag B. Congressional autism hearings continue: no evidence MMR vaccine causes disorder. JAMA 2001;285:2567-2569.
10. Yazbak FE, Lang-Radosh KL. Adverse Outcomes Associated with Post-Partum Rubella or MMR Vaccine. Medical Sentinel 2001;6(3):95-99, 108.
Dr. Orient practices internal medicine in Tucson, Arizona, and is the Executive Director of the AAPS, 1601 N. Tucson Blvd., Suite 9, Tucson, AZ 85716, http://www.aapsonline.org.
Originally published in the Medical Sentinel 2001;6(3):82. Copyright
©2001 Association of American Physicians and Surgeons (AAPS).