This article was reprinted from Mothering magazine, issue 155, JulyAugust 2009. Mothering Magazine, Inc.

2009 For more information, or to check out other available publications from Mothering, visit our website: www.mothering.com

vaccin de
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doug pIburn

ne ebate
by Jennifer Margulis

Many argue that unvaccinated children put others at risk. What does the evidence say?

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Just hours after my daughter

was born, in 1999, at Atlantas Crawford Long Hospital, a nurse bustled in with a metal tray. Time for her hep B vaccine! she announced in a chipper voice. I was 29 years old. I had never questioned the efficacy or importance of vaccines, and was completely unaware that some people suspected there might be a link between autism and vaccines. As a child, I had received the full round of recommended vaccinations. My mother is a microbiologist, my father a chemist, and I grew up with a healthy respect for science and medicine. When, in my early twenties, I spent a year working in international development in West Africa, I updated my vaccination history and got shots for several exotic illnesses, following to the letter the Centers for Disease Controls (CDC) schedule of recommended vaccines. But . . . vaccinate a newborn against a sexually transmitted disease? My husband and I had both tested negative for STDs, and had been in a monogamous relationship for three years. I looked at the tiny, perfect baby in my arms, her legs still cocked in the fetal position, whose entire life now depended on me. We told the nurse that, before we made a decision, we wanted more information about the disease and the recommended vaccination. Her eyes narrowed in anger and her entire demeanor toward us

The desire for more information about the safety, efficacy, and even the necessity of vaccines has led to a growing number of parents choosing an alternative vaccination schedule for their children.

changed, as if we were creating a health threat merely by asking questions. A few days later, during a routine visit to our pediatrician, we asked what she thought of the hepatitis B shot, and explained somewhat guiltily that our daughter had not received it in the hospital. Hepatitis B? Thats no longer recommended for newborns, she replied matter-of-factly. I have a fax about it on my desk. Its a good thing you refused that vaccine.1 We left confused, thinking how badly we would have felt had we agreed to vaccinate our daughter with a vaccine no longer recommended for newborns. We also wondered why the nurse in the hospital had been so hostile. As to why a newborn should be vaccinated against a sexually transmitted disease she had no chance of catching (unless she needed a blood transfusion, which she didnt), that question remained unanswered. The desire for more information about the safety, efficacy, and even the necessity of vaccines has led to a growing number of parents choosing an alternative vaccination schedule for their children. Some now have their children vaccinated against only certain diseases, some spread out the shots over a longer schedule, and some choose not to vaccinate at all. Newborn in arms, I began to research, realizing that in order to be educated about vaccines, I

Editors note: Due to the length of this article and the accompanying detailed references and citations, we have changed our usual style of endnotes for this article only.

NOTES 1. until I began the research for this article, I didnt know why the hepatitis b shot had been temporarily contraindicated for newborns. In July 1999, in response to public concern about thimerosal, the mercury-based preservative found in some

vaccines, the uS public Health Service and the American Academy of pediatrics issued a joint statement requesting that thimerosal be removed from vaccines, and that the birth dose of hepatitis b be withheld from newborns whose mothers tested negative for hepatitis b. [See American Academy of

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first needed to learn about the diseases they protected against. It quickly became clear that making these choices was not going to be easy; my husband and I would need to learn about and consider each vaccine individually. In the years since my oldest daughter was born, the vaccine debate has been fueled by books and articles that examine the link between autism and vaccines, and that give parents detailed information not included in the CDC-published handouts found in every doctors office. These include David Kirbys Evidence of Harm: Mercury in Vaccines and the Autism EpidemicA Medical Controversy (St. Martins Press, 2005), as well as more general books about vaccinessuch as Dr. Stephanie Cave and Deborah Mitchells What Your Doctor May Not Tell You About Childrens Vaccinations (Warner Books, 2001), Aviva Jill Romms Vaccinations: A Thoughtful Parents Guide (Healing Arts Press, 2001), and, most recently, Dr. Robert W. Searss The Vaccine Book: Making the Right Decision for Your Child (Little, Brown, 2007). Celebrities such as actress and former Playboy model Jenny McCarthy, who believes her son was damaged by vaccines, and actor Jim Carrey, have brought attention to the vaccine issue, as have books by staunchly pro-vaccine advocatessuch as Dr. Paul A. Offits Autisms False Prophets: Bad Science, Risky Medicine, and the Search for a Cure (Columbia University Press, 2008), which traces the history of the disease and concludes that there is no connection between autism and vaccines. Some vaccine advocates think the abundance of information now available, especially from websites that often are neither edited nor peer-reviewed, is unfortunate and often inaccurate. They argue that most parents are not trained scientists, and cannot effectively

pediatrics, Joint Statement of the American Academy of pediatrics (AAp) and the united States public Health Services (uSpHS), Pediatrics 104, no. 3 (September 1999): 568569. See also department of Health and Human Services, Centers for disease Control and prevention, notice to readers:

Thimerosal in Vaccines: A Joint Statement of the American Academy of pediatrics and the public Health Service, Morbidity and Mortality Weekly Report 48, no. 26 (9 July 1999): 563565.] now that thimerosal has been removed from the hepatitis b vaccine, the CdC is again recommending

that all newborns receive it at birth, at 1 to 4 months, and again sometime between 6 and 18 months, regardless of a babys risk for contracting the disease.

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but how great are the risks of the actual illnesses? Some of the diseases that still appear on the schedule of routine vaccinations are now so rare in the uS that an unvaccinated child has no quantifiable risk of catching them, and therefore no quantifiable chance of spreading them to other children.

sift through what they read to get to the truth. These vaccine proponentsincluding Dr. Martin G. Myers, a professor in the Department of Pediatrics at the University of Texas Medical Branch at Galveston, former director of the Department of Health and Human Services National Vaccine Program Office, and coauthor with Diego Pineda of Do Vaccines Cause That?! A Guide for Evaluating Vaccine Safety Concerns (Immunizations for Public Health, 2008) argue that vaccines are fundamentally safe. They believe that the risk of side effects has been grossly overreported by the media, and that this risk is negligible compared to the danger society will face if vaccine-preventable diseases reinfect the general population because large numbers of parents have stopped having their children vaccinated. I dont know any rational person who could truly be anti-vaccine, because the benefits are so profound, said Dr. Louis Cooper, Professor Emeritus of Pediatrics at the College of Physicians and Surgeons of Columbia University, and former president of the American Academy of Pediatrics (AAP), to a group of some 65 listeners at the Federal National Vaccine Advisory Committee-sponsored community meeting on vaccine safety in Ashland, Oregon,2 where approximately 28.1 percent of kindergartners had a religious exemption from vaccination in the 20072008 school year, and 24.0 percent of kindergartners filed for religious exemption for the 2009 school year. 3, 4 Vaccine advocates like Cooper argue that it has been proven that there is no link between vaccines

and an epidemic of autism. (At the meeting, Cooper publicly dismissed as crap Dr. Andrew Wakefields 1998 study,5 which pointed out the fact that vaccine-induced measles seems to occur in the intestines of autistic children and called for more research on the possible connection.) They also deny the possibility that vaccines may be partly responsible for the astronomical rise in recent years in the rates of autism, asthma, and other autoimmune diseases.6 Though, according to nationally renowned physician Dr. Robert W. Sears, to date no study of vaccine safety has used a control group of unvaccinated children large enough to be statistically significant,7 the most outspoken proponents of vaccines find no flaws in the scientific studies that purport to show that vaccines are safe, and label people who voice concerns about vaccine safety misinformers and pseudoscientists.8 Vaccine advocates argue that parents who choose not to vaccinate create a serious health risk for everyone, and that their children are safe from disease only because everyone around them is vaccinated. When you have a pocket of children who are unvaccinated, that pocket is much more likely to support contagious diseases, like whooping cough or measles, explains Dr. Offit, a pediatrician and chief of infectious diseases at Childrens Hospital of Philadelphia.9 Citing a study in the Netherlands of a 19992000 measles outbreak among 3,292 people,10 Offit argues that its not just unvaccinated children who are at risk for contagious disease: the study suggests that you are more likely to get a vaccine-preventable disease if you are

2. Ashland Middle School, Ashland, or (10 January 2009). 3. Jackson County department of Health and Human Services pamphlet, Immunization: It Takes a Village to Protect a Child (2008). 4. The 28.1 percent Ashland kindergarten religious exemption statistic comes from data compiled by the oregon Immunization program, March 2007. The Jackson County kindergarten religious exemption rate for 2007 was 6.1 percent. The Ashland kindergarten

religious exemption rate from March 2009 was 24.0 percent, and the Jackson County rate was 5.1 percent. Mothering communication with Lorraine duncan, oregon Immunization program Manager, public Health division, department of Human resources (17 April 2009). 5. A. Wakefield et al., Ileal-Lymphoid-nodular Hyperplasia, non-Specific Colitis, and pervasive developmental disorder in Children, Lancet 351, no. 9103 (28 February 1998): 637641.

6. In March 2005, the national Institutes of Health issued a 144-page report to Congress stating that autoimmune diseases, which include more than 80 chronic, and often disabling, illnesses that develop when underlying defects in the immune system lead the body to attack its own organs, tissues, and cells, collectivelyaffect 14.7 to 23.5 million people [in the uS]. For reasons unknown, their prevalence is rising. (national Institutes of Health, progress in Autoimmune diseases research

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AMY ELLIoT T

I dont know any rational person who could truly be anti-vaccine, because the benefits are so profound. LouIS CoopEr, Md
fully vaccinated and living in a generally unvaccinated community than if you are unvaccinated and living in a highly vaccinated community. The assumption that unvaccinated children put others at risk has led to widespread criticism of vaccine-hesitant parents in the mainstream press. People think youre really selfish, said JoNel Aleccia, a health writer for MSNBC.com who interviewed me.11 And its not only news media that criticize parents. In an episode of ABC s Private Practice that aired on January 8, 2009, an unvaccinated boy infected with measles in Switzerland creates a huge health scare in the doctors office, then dies. The mother had chosen not to have him and his younger brother vaccinated because her oldest son had slipped into autism after receiving vaccines. At the end of the episode, a doctor from the practice forcibly vaccinates the mothers youngest son. This episode of Private Practice was not only sanctioned by the AAP, it was created in close collaboration with them. According to an AAP newsletter sent out to members a month after the show aired,12 several AAP members had helped craft the storyline. Attached to the newsletter is a letter from AAP president Dr. David T. Tayloe, Jr. thanking Anne Sweeney, president of the Disney-ABC Television Group, for ABC s thoughtful depiction of what can happen when children are not vaccinated: This episode depicts the serious consequences that can occur when parents choose to skip or delay giving vaccines to their children for reasons

Above: dr. Louis Cooper, photographed in his home in new York City

[March 2005]: www.niaid.nih.gov/dait/pdf/ADCC_Final. pdf.) The CdCs Autism and developmental disabilities Monitoring network estimates that one in every 150 eightyear-olds in America has an autism spectrum disorder. (CdC, Autism Information Center, Frequently Asked Questionsprevalence, www.cdc.gov/ncbddd/autism/ faq_prevalence.htm) According to the CdC, 6.7 million children currently suffer from asthma. (CdC, FastStats, Asthma, www.cdc.gov/nchs/FASTATS/asthma.htm)

7. personal communication with dr. robert W. Sears, Md (10 February 2009). 8. These are terms that Martin g. Myers and diego pineda use throughout their book, Do Vaccines Cause That?! See, for example, Chapter 5, Misinformation and the return of Infectious diseases (galveston, TX: Immunizations for public Health, 2008), 76110. 9. This and subsequent quotations: personal communication (5 February 2009).

10. S. van den Hof et al., Measles Epidemic in the netherlands, 19992000 Journal of Infectious Diseases 186, no. 10 (15 november 2002): 14831486. 11. Jonel Aleccia, Vaccine-Wary parents Spark public Health Worry: More opt out for Fear of reactions, but do They Endanger Everybody Else?, MSnbC (22 August 2008): www.msnbc.msn.com/id/26291109/. 12. AAp Assists in pro-Immunization Story Line on private practice AAP News OnCall 4, no. 8 (February 2009). J u l y Au g u s t 2 0 0 9 |

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When you have a pocket of children who are unvaccinated, that pocket is much more likely to support contagious diseases, like whooping cough or measles. pAuL oFFIT, Md

Above: dr. paul offit, in his office in philadelphia

that are not based upon best medical evidence. It also attempts to present some parents fear of vaccines as just thatfearand not fact. Many young parents today do not appreciate the danger of vaccine-preventable childhood diseases because they have never seen them firsthand. This Private Practice episode illustrates the reality of one such disease at its worst, and shows the regret that can accompany a decision not to vaccinate. The implications are clear: Not vaccinating is based on uninformed decisions and puts the entire society at risk, and parents who choose not to vaccinate their children should expect them to die. I consider vaccinations a moral obligation to one another in society, said one caller to an Oregon Public Broadcasting call-in show about vaccines on which I was being interviewed about our familys choices. Identifying herself as a physician and a parent, the caller continued, Those who choose not to vaccinate rely on the rest of society to prevent epidemics of polio and measles from ravaging our communities.13 But Aviva Jill Romm, MD, author of Vaccinations: A Thoughtful Parents Guide, who spent 20 years in alternative medicine before completing a medical degree at Yale University, objects to the idea that parents who choose not to vaccinate are ignorant and irresponsible. Pediatricians need to let go of this knee-jerk reaction that parents who dont vaccinate are irresponsible, Romm contends. Many of the parents I know who have chosen not to vaccinate are actually fairly well-educated, actively contributing members of society. They are physicians, educators, people involved in government, law professors, medical professors, and academic professors.14 Dr. Robert W. Sears, MD, the son of attachmentparenting proponents William and Martha Sears and

13. oregon public broadcasting, Think Out Loud, Taking Shots, hosted by Emily Harris (7 January 2009): http://stream1.opb.org/media/tol/ episodes/2009/0107.mp3. The show and some comments are posted at www.opb.org/thinkoutloud/shows/taking-shots/. 14. This and subsequent quotations: personal communication (29 January 2009).

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H o L L I S H E A LY

author of The Vaccine Book, agrees. In Searss practice in Orange County, California, 20 percent of his 2,000 patients are not vaccinated at all, about 30 percent are partially vaccinated, and about half are vaccinated according to CDC guidelines. Its most often parents with a higher level of education choosing not to vaccinate, Sears reports, adding that this is not because these parents are smarter, but because they are more likely to question and research everything having to do with their children. Sears, who describes himself as provaccine but willing to offer alternative schedules that parents feel more comfortable with, thinks the provaccine movement is doing parents a disservice by categorically dismissing their fears about vaccine safety and labeling parents who dont vaccinate as negligent or selfish. I think that any doctor who tells a patient You have absolutely nothing to worry about, theres no chance of a severe reaction is making a false statement, Sears says. A better way to put it is, Vaccines are very important, diseases can be severe, and Id say the benefits of the vaccines outweigh the risks, but you need to be aware that there is a very small risk of a severe vaccine reaction.15 According to Sears, parents in his practice choose not to vaccinate because they would rather take the natural risk

that their child may catch an infectious illness than the perhaps small risk posed by vaccines. These parents decide that they do not want to intramuscularly inject their child with something that is artificiali.e., not part of the natural course of life. Its not a natural exposure to the disease, Sears explains, stressing that though he does not agree with this point of view, he understands it. Its chemicals, its artificial. And by giving it to their child, they are taking a risk. Even though its a smaller risk than the disease risk itself, these parents are less comfortable with that kind of artificial risk. But how great are the risks of the actual illnesses? Some of the diseases that still appear on the schedule of routine vaccinations are now so rare in the US that an unvaccinated child has no quantifiable risk of catching them, and therefore no quantifiable chance of spreading them to other children. A good example of this is polio. In the 1940s and 1950s, polio caused a serious health epidemic;16 since then, however, wild polio has been eradicated in the US. In fact, polio became so rare here that even the most staunch proponents of vaccines admit that there was a greater risk of contracting and being paralyzed by polio from the vaccine (which used to be a live virus administered orally) than contracting the naturally occurring disease itself.17 For several years there

The parents I know who have chosen not to vaccinate are actually fairly well-educated, actively contributing members of society. They are physicians, educators, people involved in government, law professors, medical professors, and academic professors.
AVIVA JILL roMM, Md

15. This and subsequent quotations: personal communication (10 February 2009). 16. Even before the development of the polio vaccine, when the disease was widespread, most infected people were asymptomatic, and less than 1 percent of cases of poliovirus infection resulted in paralysis. See note 8: 2627.

17. Ibid.

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In the absence of facts, doctors and others are trying to frighten people into vaccinating or not vaccinating. That fear includes the notions that unvaccinated children pose a great threat to others and that parents of these children are not being responsible. JAY gordon, Md

The CdC now recommends that children receive no fewer than 50 injections against 16 illnesses by the time they are 18 years oldmore than four times as many injections (including oral polio) as when I was growing up in the 1970s.

crisis now. He is less concerned about possible side effects of vaccines than he is paralyzing eight children a year.18 about the potential overall effect on the However, instead of discontinuing immune system of multiple vaccines. I mass polio vaccinationswhich were would rather use the long-term, triednow clearly more dangerous than wild and-true ways to prevent epidemics polio itselfan inactivated form of sanitation, nutrition, hygiene, healththe polio vaccine went into use. It is awarenessand save the emergency this vaccine that the CDC currently measures, like mass vaccinations, for recommends to all American children at true emergencies.21 Like polio, diphtheria is a serious 2 months, 4 months, 6 to 18 months, and 4 to 6 yearseven though the last cases of illness that once posed a quantifiable health threat in the US. It was so feared naturally occurring polio in the US were in 1979, and the last case of imported in the 19th and early 20th centuries that polio was more than 15 years ago.19 it was called the strangling angel of In fact, John Iskander, MD, MPH, children.22 However, this severe throat Associate Director for Science at the infection, which is caused by a bacterium CDC s Immunization Safety Office, tells and is treatable with antibiotics and an me that polio is now so rare in the US antitoxin, now occurs so rarely that most that it is impossible to undertake a study doctors trained within the last 20 years to assess the risk an American child has cant recognize its symptoms. According of catching the disease.20 Translation: An to the CDC , there are approximately American child not vaccinated against 0.001 cases per 100,000 population in polio poses no health risk to anyone. the US since 1980, which translates into 1 case per 100 million people, a When polio was a major health crisis, number that is barely measurable.23 the quickest way to eliminate it was to An unvaccinated Pennsylvanian who vaccinate kids against polio, says Dr. had visited Haiti died of diphtheria in Howard Morningstar, who graduated from Yale Medical School, completed his 2003,24 but no American child has died of diphtheria in the US in at least 15 years.25 residency in family medicine at Brown We do not have to worry about University, and has been working as a contracting diphtheria anymore, admits family physician in Ashland, Oregon, for 13 years. Morningstar reveals that most of John Iskander.26 Yet because the disease has not been eradicated worldwide, and his patients are not vaccinated according because other countries, particularly to CDC guidelines, But theres no polio
US children; the vaccine itself was

were zero infections of wild polio among

18. department of Health and Human Services, Centers for disease Control and prevention, Vaccines and preventable diseases: polio diseaseQuestions and Answers (6 April 2007): www.cdc.gov/vaccines/vpdvac/polio/dis-faqs.htm. See also, robert W. Sears, The Vaccine Book: Making the Right Decision for Your Child (new York: Little, brown and Company, 2007), 75. 19. department of Health and Human Services,

Centers for disease Control and prevention, Vaccines and preventable diseases: polio diseaseQuestions and Answers (6 April 2007): www.cdc.gov/vaccines/ vpd-vac/polio/dis-faqs.htm. 20. personal communication (10 January 2009). 21. This and subsequent quotations: personal communication (5 February 2009). 22. Cem S. demirci, Md, and Walid Abuhammour, Md,

diphtheria, eMedicine (updated 29 July 2008): http:// emedicine.medscape.com/article/963334-overview. 23. department of Health and Human Services, Centers for disease Control and prevention, diphtheria (6 october 2005): www.cdc.gov/ncidod/ DBMD/diseaseinfo/diptheria_t.htm. 24. p. Lurie, et al., Fatal respiratory diphtheria in a u.S. Traveler to Haitipennsylvania, 2003, Morbidity

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JA So n dAILE Y

Its one of those topics where there is fundamental disagreement even about what counts as fact. JoHn LAnToS, Md
in Eastern Europe, sometimes see spikes in diphtheria infections,27 the vaccine continues to appear on the CDC s schedule of recommended vaccines and is givenin combination with the tetanus and pertussis vaccinesto children at ages 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years. However, as with polio, an American child who has not been vaccinated against diphtheria and does not travel abroad has no quantifiable chance of spreading the disease to another American child. The same argument can be made about two other diseases on the schedule of routine childhood vaccinations: tetanus and hepatitis B. Tetanus is caused by a bacterium found in the soil, on dirty, rusty metal, and on dirty needles. A child not vaccinated against tetanus, while at risk for contracting the disease himself, poses no risk to anyone else.28 Hepatitis B is primarily transmitted through unprotected sex, the sharing of unclean needles, and from an infected mother to her newborn. Unless a child sick with hepatitis B is exchanging blood or other body fluids with another persons child, an unvaccinated child has no chance of spreading the disease. Measles is one of the diseases frequently invoked by vaccine proponents to illustrate the irresponsibility and selfishness of parents who choose to not have their children vaccinated.

Above: dr. John Lantos, shown here with his wife, Martha Montello, outside their home

and Mortality Weekly Report 52, no. 53 (9 January 2004): 12851286; www.cdc.gov/mmwr/preview/mmwrhtml/ mm5253a3.htm. 25. According to Tejpratap Tiwari, Md, medical epidemiologist at the CdC, the last reported diphtheria death in a probable (not lab-confirmed) childhood case occurred in an unimmunized fouryear-old boy in 1994. prior to that, the last diphtheria

death in a culture-confirmed childhood case occurred in an unimmunized nine-year-old female in 1982 (e-mail communication, 8 April 2009). 26. See note 20. 27. Charles r. Vitek and Melinda Wharton, diphtheria in the Former Soviet union: reemergence of a pandemic disease, Emerging Infectious Diseases 4, no. 4 (octoberdecember 1998): 539550; www.cdc.gov/

ncidod/eid/vol4no4/adobe/vitek.pdf. 28. given that tetanus is most commonly contracted by stepping on a rusty nail, some parents wonder why this vaccine would be given to children when they are two months old, and again when they are four months old, as at this age infants have no chance of getting the disease.

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If the vaccines are effective, then those who get vaccinated should have nothing to fear from the unvaccinated.
bArbArA LoE FISHEr

one study, published in the March 2009 Pediatrics, suggests that children who get measles are less likely to have allergies.

Above: barbara Loe Fisher, cofounder of the nonprofit national Vaccine Information Center and the mother of a vaccine-injured child

Unlike polio, diphtheria, tetanus, and hepatitis B, measles is a viral infection that is highly contagious and easily spread. Between 2000, when measles was declared to be eliminated from the US, and 2007, an average of 63 cases of measles were reported annually. But from January to July of 2008, 131 cases of measles were reported to the CDC , sparking widespread concern among public health officials.29 With the outbreaks of pertussis, measles, and now Haemophilus influenzae type b, says Paul Offit, we have reached a point where its clear that a choice not to get a vaccine can be harmful not only to your child but to the child who comes in contact with your child. Yet the measles vaccine is thought to have a rate of effectiveness of close to 90 to 98 percent,30 and Offit readily admits that the very small percentage of vaccinated children who might contract measles if exposed to it would have only a mild case of the disease, assuming they had some immune response to the vaccine. A child who follows the recommended guidelines for the measles-mumps-rubella (MMR) vaccine and is vaccinated against measles at between 12 and 15 months of age, and again between 4 and 6 years, should have a negligible risk of contracting the disease. Although the Private Practice episode depicted measles as a disease

that causes almost instant death, before the MMR vaccine, measles was a routine, even ubiquitous, illness of childhood that rarely led to complications in otherwise healthy children. Some health-care providers and many parents who choose not to vaccinate believe that there may be long-term benefits to getting a disease like measles, including lifelong immunity and a strengthening of the immune system overall. One study, published in the March 2009 Pediatrics, even suggests that children who get measles are less likely to have allergies.31 But whatever your opinion about measles, we know that the vast majority of measles cases are mild, and we are told that a child vaccinated against measles will have an even milder case. There seems to be no real risk to vaccinated children from unvaccinated children of being exposed to or of having any complications from this disease. If the vaccines are effective, then those who get vaccinated should have nothing to fear from the unvaccinated, points out Barbara Loe Fisher, cofounder of the nonprofit National Vaccine Information Center and the mother of a vaccineinjured child. If the vaccines are not as effective as the companies, government, and pediatricians have told us, then what a person does when they get vaccinated is they take a high risk of having a vaccine reaction as well as a high risk of

29. update: Measlesunited States, JanuaryJuly 2008, Morbidity and Mortality Weekly Report 57, no. 33 (22 August 2008): www.cdc.gov/mmwr/preview/ mmwrhtml/mm5733a1.htm. 30. W. Atkinson et al., eds., Epidemiology and Prevention of Vaccine-Preventable Diseases, 10th ed.

(Washington, dC: public Health Foundation, 2008), 138. 31. Helen rosenlund et al., Allergic disease and Atopic Sensitization in Children in relation to Measles Vaccination and Measles Infection, Pediatrics 123, no. 3 (March 2009): 771778.

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Co u r T E S Y o F b A r b A r A L o E F I S H E r

A S S o C I AT E d p r E S S

The bottom line with pertussis is that its not a perfect vaccine. JAMES SHAMES, Md
not having the vaccine work.32 What about the idea that pockets of unvaccinated children can threaten the entire herd? Because the necessary scientific studies have not been done, its difficult to answer this question. I called The Principia, a Christian Science school with two campuses, one for preschool to high school students and another for college students, in the St. Louis, Missouri, area. Christian Scientists have a wide range of beliefs, and the Church of Christ, Scientist, allows its members freedom of choice in vaccination and other types of health care; however, many Christian Scientists choose not to vaccinate their children because of their belief in the power of prayer to prevent and heal illness. Of the 1,025 students at The Principia in 2008, more than 90 percent956filed vaccine exemptions. Despite the high numbers of unvaccinated children at the school, in the past ten years there have been no outbreaks on either campus of measles or any other diseases preventable by legally mandated vaccines, and no deaths from these diseases.33 Whooping cough, aka pertussis, is another highly contagious disease that worries publichealth officials, but unlike the measles vaccine, the pertussis vaccine is only 80 to 85 percent effective.34 According to the CDC , there were approximately 25,616 cases of pertussis nationwide in 2005,35 and 15,632 in 2006.36 Most teenagers and adults who have whooping cough dont know itthe disease is mild and annoying (the cough can linger for up to three months), but usually not serious enough to warrant even a visit to the doctor. In infants, however, whooping cough can be life-threatening. The bottom line with pertussis is that its not a perfect vaccine, explains James Shames, MD, the medical director of Health and Human Services for Oregons Jackson and

Above: dr. James Shames, medical director of Health and Human Services for oregons Jackson and Josephine Counties

32. This and subsequent quotations: personal communication (15 January 2009). 33. personal communication, Laurel Walters, Communications director, The principia (April 2009). 34. See note 30: 89.

35. department of Health and Human Services, Centers for disease Control and prevention, Summary of notifiable diseasesunited States, 2006, Morbidity and Mortality Weekly Report 55, no. 53 (21 March 2008): 77; www.cdc. gov/mmWR/PDF/wk/mm5553.pdf.

36. Ibid.

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Josephine Counties, who believes the frequency of the disease is underreported.37 Whooping cough is fatal in 1 percent of the infants under the age of six months who contract it. The CDC estimates that 10 to 20 people die of whooping cough each year out of a population of 307,212,123.38, 39 Vaccine proponents worry that if everyone in Jackson County decided to refuse the pertussis vaccine (which is routinely given at 2 months, 4 months, 6 months, 1518 months, and 46 years), it would affect the well-being of the county in general, and infants could die. This fear, however, is purely theoretical, and because the studies of not based on any statistics. Ashland, which is autism and vaccines in Jackson County, has one of the lowest rates 40 do not include control of childhood vaccination in the US, but in the adult in the county has groups of large enough last ten years no child or 41 died of whooping cough. numbers of completely If a child does catch a vaccine-preventable unvaccinated children, disease, is it really possible to trace with its disingenuous certainty where the disease came from? For Jay of scientists and of Gordon, MD, a pediatrician with more than 30 the mainstream press years of experience and an assistant professor of pediatrics at the UCLA Medical School, the to claim that the link answer is no. When children or babies who between autism and have been in contact with other children (or vaccines has been adults) contract most illnesses, there is no disproved. feasible way to know from whom they got the disease, Gordon writes in First Impressions, an online companion to the Michigan Law Review.42 Whether one is talking about a routine winter viral illness, chicken pox, or whooping cough, the contagion could have come from a child with overt disease signs and symptoms, an asymptomatic carrier, or

no matter what measures you take to boost your childs natural immunity, there is no way to eliminate risk: there are risks to vaccinating, and risks to not vaccinating.

another, perhaps mutual, contact. Gordon further asserts that a parent who chooses not to vaccinate her own child is not accountable or responsible for another child contracting a vaccine-preventable disease. Instead, the burden of protecting an infant from a contagious disease is on the infants parent, not on the parents who choose not to take the risk of injecting their child with a pharmaceutical product that is known to cause adverse reactions and is not always effective. Parents must protect [infants too young to have received a full complement of shots and immuno-compromised children] by keeping them away from too many other children. Period, Gordon writes. Newborns and young babies are at risk any time they are in public. We can only vaccinate against a very small minority of contagious illnesses; it is unwise to bring your newborn into preschool when you pick up your toddler, and equally risky to attend older childrens birthday parties with this baby. 43 Public health officials point to the death of an unvaccinated baby in Minnesota in 2008 as an example of how dangerous it is not to vaccinate. But of the five children who became infected with Haemophilus influenzae type b (Hib), a bacterial infection that can cause meningitis, pneumonia, and blood and bone infections, two had been vaccinated against Hib.44, 45 About a year before, on December 13, 2007, the pharmaceutical giant Merck & Co. had recalled more than 1 million doses of the Hib vaccine because equipment used in manufacturing it was found to be infected with Bacillus cereus, a

37. personal communication (10 January 2009). 38. Centers for disease Control, pertussis (Whooping Cough)What You need to Know (13 January 2009): www.cdc.gov/features/pertussis//. 39. Central Intelligence Agency, united States, The World Factbook (updated 9 April 2009): www.cia.gov/ library/publications/the-world-factbook/print/us.html. 40. See notes 3 and 4. For the 20072008 school year,

2.1 percent of incoming kindergartners in all states filed for philosophical exemption, 0.7 percent filed for medical exemption, and only 0.3 percent filed for religious exemption, according to information compiled by self-reported data from each state by the department of Health and Human Services, Centers for disease Control and prevention and obtained via e-mail from the Centers for disease Control and

prevention, national Center for Immunization and respiratory diseases. 41. Carol Irwin, rn, Community Health nurse, Jackson County public Health, personal e-mail communication (3 March 2009). 42. Jay gordon, Md, Commentary: parents Should not be Legally Liable for refusing to Vaccinate Their Children, Michigan Law Review 107, First

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As a nurse, I had just assumed that everything we had been asked to do was based on good, solid science. But the gaps in the science are, frankly, what were still dealing with now. VICKY dEboLd, rn, pHd
bacterium associated with food poisoning and diarrhea.46 Parents in Minnesota who had their children vaccinated against Hib before the recall were unknowingly injecting their childrens bodies with a potentially contaminated product. For a vaccine proponent such as Paul Offit, who downplays the dangers of vaccines, the choice to vaccinate is the only one to make, and the death of even one child from a vaccinepreventable disease is unacceptable. But for the hundreds of thousands of parents whose children have been damaged by adverse reactions to vaccines, there is no way to quantify which childs life is more important. You cannot put a greater value on the life of a child who is injured or dies from a disease than the life of a child who is injured or dies from a vaccine reaction, says Barbara Loe Fisher. Vicky Debold, RN, who also has a PhD in Public Health, has had firsthand experience with infants who have died as a result of Hib infections. When she worked as a pediatric nurse in an ICU in the early 1980s, she saw two infants die of Hib, and worked with the grieving parents. Partly because of that experience, Debold was a staunch proponent of vaccines, and thought that people who were skeptical of them were ignorant and misguided. But in August 1998 when her own son was 15 months old, following a routine round of vaccinations,

Above: Vicky debold, at home with her son, Sam, 11, who was diagnosed with autism shortly after receiving a routine round of vaccinations

Impressions (2009): 95; www.michiganlawreview.org/ firstimpressions/vol107/gordon.pdf. 43. Ibid.: 96. 44. department of Health and Human Services, Centers for disease Control and prevention, Invasive Haemophilus influenzae Type b disease in Five Young Children Minnesota, 2008, Morbidity and Mortality Weekly Report 58 (Early release, 23 January

2009): 13; www.cdc.gov/mmwr/preview/mmwrhtml/ mm58e0123a1.htm. 45. one child had received two doses of the Hib vaccine, in accordance with the CdC recommendations for a five-month-old, another child had received two doses of the Hib vaccine, but no booster shot, per CdC recommendations at the time. given that vaccinated children far outnumber the

unvaccinated, the fact that three of the five children who were infected were unvaccinated suggests that the unvaccinated are overrepresented among those getting sick. 46. Centers for disease Control and prevention, Vaccines & Immunizations, Questions and Answers about Hib recall (27 december 2003): www.cdc.gov/ vaccines/recs/recalls/hib-recall-faqs-12-12-07.htm. J u l y Au g u s t 2 0 0 9 |

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Merck & Co., which manufactures the MMr vaccine touted as life-saving medicine in the Private Practice episode that AAp doctors helped write, donated to the AAp in the $350,000 to $499,999 category.

given the enormous amounts of money to be made from manufacturing vaccines, parents wonder how health officials and even the AAp can be impartial.

that children receive no fewer than 50 he could no longer stand up in his crib, injections against 16 illnesses by the time lost interest in walking, and started they are 18 years old48, 49more than four having bad diarrhea. I just thought it times as many injections (including oral was because his legs were sore, Debold polio) as when I was growing up in the remembers. But within a couple of 1970s50but there have been few, if any, months, I noticed that his speech had scientific studies comparing the health of stalled out. Before he turned three, Sam vaccinated and unvaccinated children,51 was diagnosed with autism.47 Although Debold had once browand to date, no scientific studies of beaten her sister into getting her daughter vaccine safety that include a statistically vaccinated, she now believes that her significant control group of children own child was damaged by vaccines. I who have received no vaccinations at think its really hard for people who have all.52 Dr. Robert W. Sears would like to actually given vaccines to think something see studies done with from 10,000 to 100,000 unvaccinated children, but such you did could have caused injury, Debold studies do not exist. In the absence of explains. Vaccines are something that I facts, doctors and others are trying to willingly participated in for my son. The frighten people into vaccinating or not natural defense as a mother and a nurse is vaccinating, writes Dr. Jay Gordon. that I didnt do anything wrong. That fear includes the notions that But the more Debold researched the unvaccinated children pose a great issue, the more skeptical she became. threat to others and that parents of these When she went to the library to find children are not being responsible. In articles that proved the efficacy and fact, these parents are choosing what safety of simultaneously receiving they consider to be the safest course of multiple vaccinations, she was shocked action for their children and pose very to find almost none. The more I little, if any, danger to other children and looked, the less I found, Debold says. adults.53 As a nurse, I had just assumed that The bottom line is that theres still a everything we had been asked to do was lot we dont know about vaccine safety based on good, solid science. But the and the long-term effects of vaccines gaps in the science are, frankly, what on the bodys immune system. Its were still dealing with now. one of those topics where there is These gaps in the research about fundamental disagreement even about vaccine safety remain a concern for what counts as a fact, declares John parents. The CDC now recommends

47. This and subsequent quotations: personal communication (13 January 2009). 48. department of Health and Human Services, Centers for disease Control and prevention, recommended Immunization Schedule for persons Aged 0 Through 6 Yearsunited States: 2009: www.cdc.gov/vaccines/recs/schedules/downloads/

child/2009/09_0-6yrs_schedule_pr.pdf. 49. department of Health and Human Services, Centers for disease Control and prevention, recommended Immunization Schedule for persons Aged 7 Through 18 Yearsunited States: 2009: www.cdc.gov/vaccines/recs/schedules/downloads/ child/2009/09_7-18yrs_schedule_pr.pdf.

50. According to barbara Loe Fisher, in the late 1970s, most children received five dpT shots (15 doses of three vaccines) and five doses of oral polio Virus at 2, 4, 6, and 18 months of age, and between 4 and 6 years, plus one dose of MMr between 12 and 15 months. More information about vaccine licensure dates can be found at a website operated by the Immunization

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I would rather use the long-term, tried-and-true ways to prevent epidemics sanitation, nutrition, hygiene, health-awarenessand save the emergency measures, like mass vaccinations, for true emergencies. HoWArd MornIngSTAr, Md
Lantos, MD, a pediatrician and bioethicist at the University of Chicago and the Center for Practical Bioethics in Kansas City, Missouri.54 We dont know if giving vaccines in combination with other vaccines is safe. We dont know if the aluminum and formaldehyde found in measurable quantities in some vaccines and injected intramuscularly into our bodies has negative health consequences. Because the studies of autism and vaccines do not include control groups of large enough numbers of completely unvaccinated children, its disingenuous of scientists and of the mainstream press to claim that the link between autism and vaccines has been disproved. When public health officials dismiss parental concerns without adequately studying them, there is an erosion of public trust. Given the enormous amounts of money to be made from manufacturing vaccines, parents wonder how health officials and even the AAP can be impartial. In 2008, the pharmaceutical firm Wyeth, which makes Prevnar, the only brand of the pneumococcal vaccine widely used in the US (the Pc vaccine is currently recommended for children ages 2, 4, 6, and 12 to 15 months), was one of the AAPs top corporate donors, giving in the $750,000 and

Above: dr. Howard Morningstar, photographed in his office in Ashland, oregon

Action Coalition and funded by the CdC . www. immunize.org/timeline. See also paul A. offit, Md, and Louis M. bell, Md, Vaccines: What You Should Know (Hoboken, nJ: John Wiley & Sons, 2003), 99. 51. dr. bernardine Healy, health editor of U.S. News & World Report and former director of the national Institutes of Health, signaled this fact on Larry

King Live (3 April 2009): I think there is so much more to learn. Simple things like a comparison of children who have and have not been vaccinated. This is something that we have talked about doing for many years. It has not been done. It can be done through various models, through case control models. It can be done retrospectively.

It has to be done. http://transcripts.cnn.com/ TRANSCRIPTS/0904/03/lkl.01.html. 52. Ibid. 53. See note 42: 98. 54. personal communication (23 January 2009).

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Vaccines are very important, diseases can be severe, and Id say the benefits of the vaccines outweigh the risks, but you need to be aware that there is a very small risk of a severe vaccine reaction.
dr. robErT W. SEArS, Md

Above: dr. robert W. Sears, near his home in Southern California

Above category.55 Merck & Co., which manufactures the MMR vaccine touted as life-saving medicine in the Private Practice episode that AAP doctors helped write, donated to the AAP in the $350,000 to $499,999 category.56 Paul Offit, who wrote an article excoriating Dr. Robert W. Searss alternative schedule that was published in Pediatrics, the AAPs peer-reviewed journal,57 himself has a clear financial conflict of interest: coinventor of the RotaTeq vaccine, he is also a coholder of the patent on it.58 Merck isnt dumb, Dr. John E. Trainer III, a family physician in Jacksonville, Florida, wrote me in an e-mail. Although Trainer describes himself as very pro-vaccine, he understands why parents have concerns: Two of his own four children have suffered vaccine-induced complications. They arent doing this (solely) to be nice. And they are making enough money to hire a sales force. They visit us and other docs to try to sell more vaccines.59 In the last three years, three new Merck vaccines have been approved by the federal government for sale: RotaTeq, Zostavax, and Gardasil. What does it mean to force everybody to be vaccinated? asks Dr. Howard Morningstar. Its a philosophical decisionits not based on rational scientific facts. After reading everything we could about vaccines, calling the CDC , and talking to dozens of people in the health-care professions and other parents (most of whom had chosen to vaccinate), my husband and I chose not to vaccinate our children against hepatitis B or any of the other childhood illnesses. Making our choices vaccine by vaccine, we agonized over whether each was the right choice. We also did everything we could to help our children have healthy immune systems to fight any diseases their bodies might be exposed to.

55. American Academy of pediatrics, Honor roll of giving, AAP News 29, no. 11 (november 2008): 23. 56. Ibid. 57. paul A. offit and Charlotte A. Moser, The problem with dr. bobs Alternative Vaccine Schedule, Pediatrics 123, no.1

(January 2009): e164e169; http://pediatrics. aappublications.org/cgi/content/full/123/1/ e164. 58. Ibid. 59. personal communication (26 January 2009).

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doug pIburn

I breastfed them well past two years, and we educated ourselves about good nutrition and changed our eating habits. We also gave away all of the poisonous cleaning products in our house, began buying organically grown foods, and made sure our children got enough exercise, sleep, and outdoor time. Then, in 2006, when the children were six, four, and two years old, I was awarded a Fulbright fellowship to teach and do research in Niger, West Africa, one of the poorest countries in the world, where diseasesincluding typhoid fever, malaria, measles, schistosomiasis, meningitis, giardiasis, dengue fever, and hepatitisare common. A yellow-fever vaccine is required for entry into the country. After revisiting every childhood illness and assessing the health risks posed by international travel, we decided to vaccinate our children against only three other diseases, besides yellow fever: polio, tetanus, and meningitis. We used the German-made tetanus-only vaccine instead of a DPT combination, and spaced out the shots, one at a time, over a period of several months, so that if our children had a bad reaction, we would know which vaccine it was. No matter what measures you take to boost

your childs natural immunity, there is no way to eliminate risk: there are risks to vaccinating, and risks to not vaccinating. It is counterproductive to terrify parents into vaccinating their children, or to vilify those who choose not to. In the US, we have the right to refuse a pharmaceutical product, and it doesnt surprise me that more parents than ever are exercising that right. The CDC , the drug manufacturers, government spokespeople, vaccine advocates, and vaccine skepticsmost of those who make up each of these groups are also parents. As parents, we all have a common goal: to keep our children and our nation as healthy as possible.

As parents, we all have a common goal: to keep our children and our nation as healthy as possible.

Interested in finding out more about the vaccine controversy? Log on to www.mothering. com/links for access to our entire section on vaccines, including the past article, Chickenpox Party by Brian Wimer, Jacquelyn L. Emm, and Deren Bader; the Vaccinations forum on our discussion boards; the Vaccines: Mercury, Autism & Chronic Disease reprint (available for purchase); and a special video of Vicky Debolds son, Sam, playing piano. Jennifer Margulis, PhD, is a professional writer and the mother of three (9, 8, and 5). She lives in Ashland, Oregon, and was a Fulbright Scholar in Niger from 2006 to 2007. Read more about her at www.jennifermargulis.net.

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va riva x:
once exposed to wild chicken pox, you have immunity, which is important: The disease is almost always more serious in adults than in children.

more harm than

by the chicken-pox virus. We now have an epidemic of shingles among older children and adults which is far more expensive and actually far more painful than if we had let chicken pox remain endemic in the population, and used the vaccine selectively, explains Fisher. According to the CDC , approximately 1 million people a year now get shingles,4 and there is an increasing body of scientific data showing that the number of adults suffering from shingles is on the rise. One study showed a 90 percent increase in the number of adults infected with the Herpes zoster (shingles) virus in Massachusetts from 1999 to 2003 as the chicken-pox vaccine become more widespread.5 Other studies have estimated increases as well.6, 7 John Grabenstein, Senior Medical Director, Adult Vaccines, Merck & Co., Inc., argues that the very slight recent rise in shingleswhich, he says, is something Merck & Co. also found in their shingles prevention study of more than 38,500 people8is not related to the chicken-pox vaccine. Shingles was with us even before the childhood vaccine came along, Grabenstein points out. Its not correct to say that because we are vaccinating children, therefore adults are getting shingles.9 Instead, Grabenstein attributes the rise in shingles to the rising life expectancy among American adults. The longer you live, the greater your risk of getting it, he says. He discounts the idea that re-exposure to the wild virus circulating in the population provides a potential boost to the immune system and is preventive. Your exposure to your grandkids is a minor player, Grabenstein insists. The dominant reason shingles occurs is that the immune system ages along with the body. What everyone does agree on is this: shingles is a potentially serious and terribly painful disease. To address the shingles

Some parents and many doctors

were surprised by the introduction in 1995 of the chicken-pox vaccine as part of the CDC s schedule of routine vaccinations. Vaccines have historically been developed to protect children against serious childhood illnesses, but chicken pox, a viral infection also known as varicella, has always been a mild disease. Until the vaccine was introduced, it caused about 100 deaths each year,1, 2 and about half of those deaths were among children. According to Barbara Loe Fisher, cofounder of the National Vaccination Information Center and co-author of the book A Shot in the Dark (1985), about the dangers of the whole-cell pertussis vaccine, the vaccine was first designed for children with compromised immune systems, but once Merck & Co. had developed the vaccine, they needed to find a market for it. 3 (Varivax, the only chicken-pox vaccine used in the US , is made by Merck.) Now that the chicken-pox vaccine is required for enrollment in most public schools, there are far fewer cases of chicken pox in the US . On one hand, this is a good thing: Fewer children miss school, parents dont have to take time off work, and currently there are fewer than five deaths per year from wild chicken pox. Yet these positive benefits come with an unforeseen downside. Once exposed to wild chicken pox, you have immunity, which is important: The disease is almost always more serious in adults than in children. Previously, when wild chicken pox broke out in the general population, the immunity of adults who had been exposed to it as children would be boosted by periodically coming in contact with the disease. But now that the natural immunization boost is effectively gone, this has led to growing numbers of baby boomers who had chicken pox as children getting shingles, a more serious disease caused

We now have an epidemic of shingles among older children and adults which is far more expensive and actually far more painful than if we had let chicken pox remain endemic in the population, and used the vaccine selectively.
bArbArA LoE FISHEr

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go o d?
problem, Merck has developed a new vaccine: Zostavax, licensed by the FDA in May 2006, and now being recommended for everyone over 60. Fisher finds this troublesome. You have a situation that was created by vaccination and you have a vaccine to counteract that situation, she notes. Its not only vaccine skeptics who are concerned. Dr. John E. Trainer III, a family physician in Jacksonville, Florida, who describes himself as very pro-vaccine, has questions about the cost of Zostavax and its effectiveness. Its a coin toss of efficacy, he says. If I give it to a 60-year-old, they are 50 percent likely to benefit from it. That means you can flip a coin and see whether it works or not. The vaccine is expensive, and the cost to the patient varies widely, depending on insurance coverage. My partner and I have not embraced the shingles vaccine.10 In addition to the problem of an upsurge in shingles, the chicken-pox vaccine, which is a live virus, can cause several side effects that are as or more dangerous than the disease itself. Since the chicken-pox vaccine came into widespread use, reported reactions to it have included bleeding disorders, pneumonia, skin infections, severe rashes, and such nervous-system problems as Guillain-Barr Syndrome, encephalitis, and seizures.11, 12 Two young patients of Dr. Robert W. Sears who received the vaccine have developed benign thrombocytopenia, a blood-clotting disorder.13 Both of the children in Searss practice were hospitalized, and both took more than two months to recover. This doesnt make me stop giving that vaccine, Sears states. It just makes me realize that these reactions can happen.
I S T o C K p H o T o . Co M

NOTES 1. department of Health and Human Services, Centers for disease Control and prevention, Vaccine Information Statement (Interim): Varicella Vaccine, Chickenpox Vaccine: What You need to Know, 42 u.S.C. (13 March 2008): 300aa-26; www.cdc.gov/vaccines/pubs/vis/downloads/vis-varicella.pdf. 2. For an extended discussion of how the CdC numbers may be misleading, see brian Wimer, Jacquelyn L. Emm, and deren bader, Chickenpox party: developing natural Varicella Immunity, Mothering 122 (JanuaryFebruary 2004): 3037; www.mothering.com/articles/growing_child/child_health/ chickenpox_party.html. 3. personal communication (15 January 2009). 4. department of Health and Human Services, Centers for disease Control and prevention, Vaccines and preventable diseases: Shingles diseaseQuestions and Answers (Herpes Zoster) (19 october 2006): www.cdc.gov/vaccines/vpd-vac/ shingles/dis-faqs.htm. 5. W. K. Yih et al., The Incidence of Varicella and Herpes Zoster in Massachusetts as Measured by the behavioral risk Factor Surveillance System (brFSS) during a period of Increasing Varicella Vaccine Coverage, 19982003, BMC Public Health 5 (16 June 2005): 68. 6. g. S. goldman, Cost-benefit Analysis of universal Varicella Vaccination in the u.S. Taking into Account the Closely related Herpes-Zoster Epidemiology, Vaccine 23, no. 25 (9 May 2005): 33493355. 7. g. S. goldman, The Case Against universal Varicella Vaccination, International Journal of Toxicology 25, no. 5 (Septemberoctober 2006): 313317. 8. M. n. oxman et al., A Vaccine to prevent Herpes Zoster and postherpetic neuralgia in older Adults, New England Journal of Medicine 352, no. 22 (2 June 2005): 22712284; http://content. nejm.org/cgi/content/full/352/22/2271. 9. This and subsequent quotations: personal communication (13 April 2009). 10. personal communication (23 January 2009). 11. See note 1. 12. Merck & Co. Inc., Varivax: Varicella Virus Vaccine Live (Whitehouse Station, new Jersey: november 2008): www. merck.com/product/usa/pi_circulars/v/varivax/varivax_pi.pdf. 13. personal communication (10 February 2009).

Since the chicken-pox vaccine came into widespread use, reported reactions to it have included bleeding disorders, pneumonia, skin infections, severe rashes, and such nervous-system problems as guillain-barr Syndrome, encephalitis, and seizures.

Jennifer Margulis

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