It’s hard for me to believe that it’s been approximately 16 years since I first discovered that there was such a thing as antivaccinationists. Think of it this way. I was around 37 or so when, while wandering around Usenet (remember Usenet?), I found the newsgroup misc.health.alternative (or m.h.a. for short), a discussion group about, appropriately enough, alternative medicine. It was there that I first encountered the claim that vaccines cause autism, sudden infant death syndrome, autoimmune diseases, and a panoply of just about every chronic disease known to humankind. Much like when I had first discovered Holocaust denial a couple of years before that, I was floored that such beliefs existed. Given the evidence, I couldn’t believe that there were people out there who thought vaccines were harmful.
The more I engaged with the antivaccine fringe on m.h.a, the more I came to realized just how far off the deep end many antivaccinationists are and just how full of conspiracy theories. By the time I started my blog in December 2004, I had become pretty well-versed in antivaccine misinformation and tropes and how to combat them. Then, in June 2005, I wrote my first big refutation to a major antivaccine article by Robert F. Kennedy, Jr in—to their eternal shame—Salon.com and Rolling Stone, and my course was set. Dealing with antivaccine pseudoscience became one of the most common topics on this blog and has remained so ever since. Unfortunately, over the years, the antivaccine movement didn’t go away. It got louder and better at social medial, which is why in comparison I often feel that skeptics are outgunned, even though we have science on our side.
My thinking on what the best policy is to ensure maximal vaccine uptake and therefore maximal protection of children from vaccine-preventable diseases, as well as protection of children who can’t be vaccinated for medical reasons, which brings me to the American Academy of Pediatrics (AAP) position paper on vaccine hesitancy and refusal, published about a week ago in Pediatrics. In this paper, the AAP advocates eliminating nonmedical exemptions to vaccine mandates:
Children who are philosophically exempted from vaccination not only are at greater risk of developing vaccine-preventable disease but also put vaccinated children and medically exempt children who live in the same area at risk.33–35 Vaccine-preventable diseases occurring in vaccinated children may result from waning immunity after immunization or may be attributable to an ineffective immune response to vaccine initially. In January 2015, a measles outbreak occurred in California, where an estimated 3.1% of kindergartners had a nonmedical exemption from receiving the measles–mumps–rubella (MMR) vaccine.36 The majority of cases occurred in children who either had not received measles vaccine (45%) or had unknown vaccination status (38%).37 Of the cases in unvaccinated children, 43% of parents cited philosophical or religious objects to vaccine. An additional 40% of unvaccinated children could not receive the vaccine because they were too young. This outbreak, which spread to multiple states, has sparked intense debate about vaccine exemptions and the government’s role in limiting nonmedical exemptions. Whether the 2015 outbreak and legislation resulting from this outbreak will have a long-lasting effect on public policy and parental choices is not clear at this time. For these reasons, we believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines, a position that is shared by the American Medical Association and the Infectious Diseases Society of America and is currently the basis of a policy statement being developed by the AAP.
In the US, states mandate that certain vaccines, usually the vaccines on the CDC recommended immunization schedule, are required before children can be enrolled in school. There is no “forced vaccination,” as antivaccinationists like to mischaracterize it, but there are consequences for parents who don’t vaccinate. They won’t be able to enroll their children in day care or public school unless they are up-to-date on their vaccines.
There are, of course, exceptions. These come in two varieties. First there are medical exemptions. If a child is, for instance, immunosuppressed because he has cancer and is receiving chemotherapy, then certain live attenuated virus vaccines are not safe to administer. Then, of course, there are what are referred to as personal belief exemptions (PBEs), which come in two flavors: religious exemptions and philosophical exemptions. To me philosophical exemptions boil down to “I don’t wanna.” However, if religious exemptions are granted, it’s very problematic not to grant philosophical exemptions because such a policy not only privileges religious beliefs above nonreligious beliefs but can put the government in the position of deciding what is and is not a religion.
Be that as it may, PBEs have been a major problem over the last decade or so. As the antivaccine movement became more vocal, PBEs became more common, particularly in states that made it easy to get them. As a result, there were more and more pockets where vaccine uptake decreased to the point where herd immunity was compromised. This led to a number of attempts to make it more difficult to obtain nonmedical exemptions, because there is good evidence that lax standards for nonmedical exemptions are associated with increased pertussis incidence. Usually, the strategy has been to require that the parents have a doctor sign their exemption form after receiving counseling about the dangers of not vaccinating. California tried that strategy with AB 2109, although Governor Jerry Brown watered it down with a signing statement. My own state of Michigan has instituted a policy that requires parents seeking nonmedical exemptions to visit their local health department for state-sanctioned counseling before they can have an exemption. In neither case were parents prevented from receiving a PBE, but the process was just made intentionally more difficult, with counseling that might persuade some fence sitters to vaccinate. Policies like this work, too. In Michigan, for instance, vaccine exemptions declined after they became more difficult to obtain.
This brings me back to my evolving view. Steve Novella recalls a time when the Vaccine Committee at the Institute for Science in Medicine was debating what our position should be regarding vaccine mandates. While we all agreed that in an ideal world there would be no nonmedical exemptions, there was a huge disagreement between what I like to refer to as the pragmatists (which included me) and those in favor of no compromise. The question was over whether or not opposing nonmedical exemptions should be our only position or whether we should include an option in which we advocated that states that do allow non-medical exemptions should make them as difficult as possible to obtain. The concern was that the political calculus was such that banning nonmedical exemptions was not feasible in most states. And it was.
In retrospect, I still don’t think that was the wrong compromise. However, since the Disneyland measles outbreak, the political calculus has changed, at least in California, which led to the passage of SB 277, a law that did eliminate nonmedical exemptions. However, I must disagree with Steve, who thinks the political climate is such that now is a good time to lobby for eliminating nonmedical exemptions. I have no problem with doing that, but I am not nearly as optimistic as Steve that progress will be made. That’s because, unfortunately, in the rest of the country the political calculus appears not to have changed that much; it’s hard not to note that, as of yet, no other state has emulated California, and there are now only three states that do not allow nonmedical exemptions. So I still think that eliminating nonmedical exemptions is the ideal policy, but that in states that still allow nonmedical exemptions, PBEs should be made as difficult as possible to obtain. Still, it’s good to see the AAP come down on the side of children here, and I actually do hope that Steve is correct that the political will is finally coalescing. Unfortunately, the extreme pushback from antivaccine activists in California might deter other state legislatures from fallowing suit.
The AAP also discusses strategies for dealing with vaccine hesitancy. As I’ve discussed this issue in depth recently, I’ll try to restrain my more “Oracian” tendencies towards logorrhea. I will note, however, that the AAP reiterates that the vast majority of vaccine-hesitant parents are reachable with information and persuasion. They’ve just been misinformed. It’s only a relatively small percentage who are hardcore antivaccine who are unpersuadable. The AAP also notes that countering vaccine hesitancy is hard and a source of pediatrician dissatisfaction with their jobs:
Providing vaccine information is time consuming. Kempe et al56 found that 53% of physicians spend 10 to 19 minutes discussing vaccines with concerned parents, and 8% of physicians spend 20 minutes or more with these parents. They also reported that pediatricians experienced decreased job satisfaction because of time spent with parents with significant vaccine concerns. Physicians have several options to deal with this problem, ranging from scheduling longer well-care visits, with some loss of overall efficiency; simply not having the discussion and acceding to a parent’s request to defer, delay, or skip a vaccination; or dismissing such families from their practice. Permitting alternative vaccine schedules reduces vaccine timeliness and complicates an already complex vaccine schedule.57 A study by Robison et al3 demonstrated that children whose parents chose to limit vaccinations had more total visits for immunizations and by both 9 and 19 months of age were substantially less likely to be caught up on their immunization series. The additional time and costs associated with longer and more frequent well-child and immunization visits for parents with vaccine concerns are substantial, and by decreasing the efficiency of primary care providers, they may have a significant effect on access to health care services for all children.
When discussing vaccines with primary care pediatricians over the years, I’ve acknowledged that I couldn’t do their job and one reason would be all the dealing with antivaccine and vaccine-averse parents. I can see how draining that could be. On the other hand, we should value pediatricians who can do this well because, as the AAP puts it:
With all the challenges acknowledged, the single most important factor in getting parents to accept vaccines remains the one-on-one contact with an informed, caring, and concerned pediatrician.58 In a study reported in Pediatrics, parents of more than 7000 children 19 to 35 months of age were surveyed to determine whether they believed vaccines were safe and what influence their primary care providers had on their decisions to vaccinate.45 Nearly 80% of parents stated that their decision to vaccinate was positively influenced by their primary care provider. The study concluded, “Health care providers have a positive influence on parents to vaccinate their children, including parents who believe that vaccinations are unsafe. Physicians, nurses, and other health care professionals should increase their efforts to build honest and respectful relationships with parents, especially when parents express concerns about vaccine safety or have misconceptions about the benefits and risks of vaccinations.” In another study, Smith et al59 clearly demonstrated that parents whose children were vaccinated listed their pediatrician as a strong influence on their decision to vaccinate. A well-informed pediatrician who effectively addresses parental concerns and strongly supports the benefits of vaccination has enormous influence on parental vaccine acceptance.
I must admit that this passage annoyed me not because it is incorrect but because it is insufficiently inclusive. It only mentions pediatricians. What about advanced practice nurses (APRN)? What about nurses? My wife is a pediatric primary care APRN. She vaccinates at least as many children as any pediatrician and she has become quite good at dealing with the vaccine-averse. The point still resonates, though. An informed, caring, and concerned provider can make a huge difference.
The AAP position paper is welcome in that it’s a lot more hard line than previous AAP statements. For example:
The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view.44 Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option. In all practice settings, consistency, transparency, and openness regarding the practice’s policy on vaccines is important.
I’ve always been conflicted on the ethics of dismissing parents who won’t vaccinate, but I can definitely see a rationale justifying such an action if such parents are taking up too much of a pediatrician’s time and potentially exposing his other patients, particularly those who can’t be vaccinated.
One thing that’s missing from the AAP statement is a discussion of pediatricians who promote antivaccine misinformation, such as “Dr. Bob” Sears, who not only promotes antivaccine pseudoscience but is basically selling highly dubious medical exemptions online to help parents get around SB 277. The AAP needs to come out forcefully to condemn such physicians in no uncertain terms and then to take action to show that their words are more than just words. That action would be to expel such pediatricians from their organization.
Overall, however, that quibble aside, the AAP statement is welcome, as it strongly emphasizes the importance of vaccination and advocates unequivocally for the strongest policies to encourage it.
- Log in to post comments
Dr. Bob on his Facebook page raised the question whether he should resign from the AAP, if it's taking such a hard line.
After posting an inaccurate article (as usual) from his new outfit, which is named Immunity Education Group. Inappropriately, because all there are articles that I've seen are inaccurate and not a good educational source.
I'm guessing Dr Bob gets very little benefit from his membership in AAP. His victims customers are not looking for a doctor but rather an excuse to break the law and endanger their kids. And to pay handsomely for the privilege.
Dr Bob should resign from the AAP, since he is a lousy example of a pediatrician. Personally, I wouldn't recommend him to anyone.
And I'm still thinking Dr Jay should do the same, unless he actually admits that vaccines work, that they do have some minimal risks but the overall benefits outweigh the risks, and that he will abide by the vaccine schedule set by the CDC unless there are specific patient indications (which should be few in number) to delay a vaccine.
One thing that’s missing from the AAP statement is a discussion of pediatricians who promote antivaccine misinformation, such as “Dr. Bob” Sears, who not only promotes antivaccine pseudoscience but is basically selling highly dubious medical exemptions online to help parents get around SB 277. The AAP needs to come out forcefully to condemn such physicians in no uncertain terms and then to take action to show that their words are more than just words. That action would be to expel such pediatricians from their organization.
If I could agree > 100% with this paragraph, I would, Orac. Very publicly anti-vax pediatricians Sears, Gordon and (now) Paul Thomas--all not just pediatricians, but members and Fellows of the AAP (FAAPs) have not endured one breath of criticism from the AAP for their actions that have scared far too many parents into not vaccinating their children. The reason for this lack of action, annoyingly, appears to be a fear by the AAP of being sued for libel (see 3rd paragraph at http://tinyurl.com/grtedua ), which is a needless fear if these three quacks were called out and expelled from the AAP based on the scientific facts regarding vaccines as well as the fact that these three are publicly advocating --as FAAPS--for patient care that is far, far below the standard of care. Sears, Gordon and Thomas need to get the brown suppository from the AAP to show the AAP is truly serious about combatting anti-vaccinationism. Somewhat tangential to this but concerning is that I suspect the AAP does not have a well-defined Code of Ethics for membership, unlike the AMA and the AAFP (who uses the AMA Code of Ethics). Nor are the AAP by-laws publicly accessible to see if a discipline/expulsion mechanism is present there either. The AMA and AAFP have clear policy for revoking membership in their organizations. It is not at all clear the AAP does has any such policy (and if they do they are keeping locked on a box high on a shelf somewhere really, really secret)
The AAP also needs to step up and denounce (on their web sites and actively online) anti-vax groups such as the NVIC, Mercola, Natural News, GreenMed, Tenpenny, etc. I think the AAP doesn't want to dirty itself in the trenches, but the problem is when well-meaning parents want to see what the AAP thinks of these groups (that say terrifyingly untrue things about vaccines), they can find no specific addressing of these groups by name by the AAP. That, to many parents, probably comes across as an endorsement by silence by the AAP. Drop the pom-poms AAP, and get on the field. This is how you convince parents to vaccinate.
@Dorit #1: Sears is just pandering to his parents. Sears will (to paraphrase one of Sears' own most outlandishly selfish pieces of advice he gives to parents in his first "vaccine book" when he recommends not vaccinating) continue to hide in the herd of pediatricians who do vaccinate as long as the AAP will allow him.
@ MI Dawn--have you seen Gordon's "Vaccines" DVD? It's as anti-vax as anything out there, including anything by Sears. As Gordon has not recanted a single thing on it, he deserves expulsion as well.
@Chris Hickie: no. I make it a practice NOT to watch things that induce extreme rage or vomiting.
My only consulation is that my whole family is UTD with vaccines and I know that any grandchildren I may have will be vaccinated (barring valid medical reasons).
"I’m guessing Dr Bob gets very little benefit from his membership in AAP."
Well, the more letters you can put after your name, the better. Embracers of quackery love Experts Who've Recanted, and trumpet their credentials (as if being an FAAP signified anything more than passing one's boards and paying membership dues). The equal or better credentials of the vast majority of responsible physicians do not matter, because, ya know, they just swallow the party/Pharma line and do what they're told.*
*as well as being "hunchmen". ;)
I just want to note that there's often a difference between the formal policy positions of organizations and what they actually attempt to achieve on the ground. E.g., political parties have platform planks they have no intent to make priorities for moving legislation. Thus, action can remain 'pragmatist' while philosophy becomes more 'hard core'. Certainly it's a common tactic to open any sort of negotiation with a position from which concessions can be yielded resulting in an acceptable compromise. In states where eliminating all non-medical exemptions would be a bridge too far, while it would unwise to employ a 'no PBEs or bust!' strategy, in the absence of that 'hard core' action, the 'hard core' AAP position statement should be useful in working toward "getting non-medical exemptions as difficult as possible to obtain."
More broadly, outside of actual policy decisions, statements of organizational positions help change the rhetorical environment shaping public opinion. In the past, pro-vax rhetors have been hampered by institutional silence. The audience could wonder 'how credible can you be when your profession as a whole doesn't appear to support your position?' The AAP statement is thus important 'backup' for any attempt by PCPs (or others) to persuade vax-hesitant patients to get off the fence on the right side.
Not that the responsibility for carrying the pro-vax argument to the vax-hesitant should all be dumped onto pediatricians, but that's another comment.
Yeah, in retrospect I probably should have said something about the AAP dumping the responsibility primarily on its members. On the other hand, they are the ones in the trenches doing it anyway. What they need, though, is more support—and, quite frankly, more reimbursement, given how much time dealing with the vaccine-averse takes.
Laura Hayes, of course, does not miss this opportunity to bring the batsh*t crazy:
This seems to be a call for Dr. Bob et al. to resign from the AAP, or else.
The American Academy of Pediatrics does a lot of very good things including supporting pediatricians who cannot be members like Dr. Hickie.
Additionally, the AAP has fought for single payer plans and the ACA. AAP outreach programs help countless children each year, too.
There have been decades of unethical cooperation between AAP leadership and the infant formula industry. I long ago decided that resigning over this issue would be far less effective than staying in the AAP and, in fact, I serve on the AAP Section on Breastfeeding. It is a tent big enough to hold us all. Our leaders are finally acknowledging these problems and working to solve them. Perhaps pressure from peds like me helped.
The most recent non-medical exemption statement was far less draconian in scope than I expected and affirms the letter and spirit of California's newest law. A doctor who knows the child decides whether a medical exemption is warranted. This is no different than all medical decisions involving our patients. A very recent publication showed very clearly that when we speak to parents and gain their trust, families who had originally intended to not vaccinate instead vaccinate.
Stick with your unscientific approach about "pro- and anti-" vaccine because it's easier for you. The truth is that there are thousands of pediatricians and perhaps millions of parents who want to deviate from the schedule but give kids shots, too.
All My Best,
Supporting evidence needed.
Not always. And any deviation from the schedule has the potential to expose the child, and those children in the practice too young to be vaccinated and those who are immunocompromised to diseases. Some physcians have decided that this risk is too great and I agree with them.
And what, pray tell, qualifies these parents to think that the schedule is bad and that deviating from it is acceptable?
I believe it is disingenuous for anti-vaxers (and even folks like Dr. Gordon) to talk about the "one-size fits all" schedule.
I've not only researched the schedule, but I've participated in it through my children (well, and me too, of course, when I was younger).
The recommended schedule is spread over months and years - it isn't like kids are getting shots constantly & each vaccine has a recommended window, which again, is spread over months or even years between doses.
To say that there isn't flexibility is just a blatant lie.
Actually Jay, to say I "cannot" be a member of the AAP is incorrect. I am currently not board-certified in pediatrics (I was from 2003-2010) because I let my board certification lapse when MOC was rolled out. I had more important things to do at the time like keeping my practice afloat (I don't gouge parents in a cash-only setting like you do, Jay--I actually take care of people who depend on health insurance plans (aka the common people)) and combating anti-vax menaces like you and Sears. I also didn't agree with the philosophy behind MOC when it was rolled out. As soon as I recertify in pediatrics, I can rejoin the AAP, but I will not until they expel you and Sears and now Thomas.
Also Jay, you forgot to mention how you have been grandfathered into permanent board certification in pediatrics as can be seen on the ABP page. When was the last time you actually re-certified in pediatrics?
Please tell the whole story and not the "holistic" story--that is unless you want henchmen and hunchmen all over your case about it.
Thank heaven MOC isn't as onerous in surgery as it is in the medical specialties. We have to do some extra CME with followup exams, and we have to keep track of our cases and complications, but the stuff I hear about MOC in internal medicine and other specialties is ridiculous.
So, Jay, how do you feel about Mark Blaxill's claim – recently horked back up by Kim Stagliano – that the AAP is "the [labor] union of American pediatricians"? Let's get a bit more of the fragrance:
"Their job is to defend the commercial interests and reputations of their constituents regardless of what the larger social interest might be. One activity of the AAP is to lobby the Federal Government to spend more money to help pediatricians to make more money.
". . . .
"Make no mistake; the driving force behind the economic livelihood of a modern pediatrician is the childhood immunization program."
i wouldn't consider a professional that wants to deviate from the best practices of his/her profession particularly qualified to practice, Dr Jay.
Not unexpectedly, another article was released in Pediatrics today:
Should Pediatric Practices Have Policies to Not Care for Children With Vaccine-Hesitant Parents?
"There may be good reasons why pediatricians should not care for children whose parents refuse immunizations. However, neither a breakdown in the physician–patient relationship nor the risks to other children in the waiting room are good reasons to do so."
One of the reports mentions that:
"Physicians have several options to deal with this problem, ranging from scheduling longer well-care visits, with some loss of overall efficiency; simply not having the discussion and acceding to a parent’s request to defer, delay, or skip a vaccination; or dismissing such families from their practice."
Yet another option is to change how we talk to our patients about vaccines. Many are just scared because of things they read or things their friends and family members tell them, from myths about fetal tissue in vaccines to being scared about mercury or formaldehyde. The pediatrician who has ready answers to all of these myths and can direct parents to helpful educational material won't have to have long arguments and should have an easier time getting their kids vaccinated and protected.
Julian, research on the AAP’s relationship with the formula industry is very, very easy to find. Even Dr. Hickie will back me up on this (one) point.
Certainly we have to consider what you’ve said about babies too young to be vaccinated. Many parents respond better to respect and information than to coercion.
Lawrence, the CDC and AAP recognize no flexibility. I’m glad you perceive some and have experienced the same.
Chris, did you receive my email? Yes, keeping a primary care practice “afloat” is time consuming and, yes, I’m grandfathered but still have to complete the same CME regimen that you do. You, Orac and I all agree on MOC being onerous. You persist in threatening “henchmen and hunchmen??” Stop threatening. Thanks.
Narad, the AAP is our labor union. They protect the economic interest and working conditions of pediatricians. That’s not a bad thing you know. The AAP is also tasked with protecting and enhancing the health of American children. I don’t agree with the last statement about “the driving force” because I have come to learn that vaccines are not very profitable for most pediatricians.
He knows this Dr. Hickie, he just wants to get a dig in at you all the while sitting idly on his grandfathered status.
Oh, really? Tell me, then, the strict schedule for the HepB or polio vaccines? To which month do they limit the flu vaccine doses? Or the Hep A series?
Wait. No, I'm being too generous to the CDC. Which day after birth must vaccines be given? I mean, they recognize "no" flexibility, so they must clearly dictate the exact day and time for each vaccination, right, Dr. Jay?
Here's the truth, Dr. Jay, (and a link to the current schedule, since you've apparently forgotten it). The recommended schedule does allow for flexibility. There are recommended windows within which kids should get immunized, but they are just that, recommendations. And those windows can be pretty broad, so that if a parent is hesitant about giving a bunch of vaccines on the same day, they can get one shot toward the beginning of the month, another in the middle or toward the end. But even if a parent wants to deviate from the recommendations, the CDC isn't going to hunt down the parent and force their kid to get vaccinated, which is what would happen if they allowed "no" flexibility.
Oh, and then there are those kids who aren't able to get immunized at a visit because of a contraindicated illness. CDC isn't going to force those kids to get the shot.
And then there are those catch-up schedules. Why would they need to put those on there if they were so inflexible?
Once again, Jay, you disgrace yourself and show that you care more for your ideology than actual facts.
I suppose it also bears adding, since Jay appears to lack proper understanding of the schedule, that the shots are arranged on the schedule as they are based on science showing what is the optimal time to give vaccines to provide the greatest protection while minimizing the risks.
Are you willing to head over to AoA and tell this to the frothing lunatics who primarily make up the authors and commentariat?
Thanks Todd - I was going to point that out as well.....and for parents in California who are concerned, they have 5 - 6 years to get the necessary vaccines for school...that's plenty of time to space it however they wish.
No one, not the CDC, not the AAP, not anyone, is telling these parents exactly which day or even month these vaccines should be given....
' frothing lunatics who primarily make up the authors and commentariat?'
You have a way with words, Mister.
Jay: "The most recent non-medical exemption statement was far less draconian in scope than I expected and affirms the letter and spirit of California’s newest law. A doctor who knows the child decides whether a medical exemption is warranted."
I didn't see anything in the AAP position statement supporting antivax pediatricians who conjure up medical exemptions based on flawed and downright bogus indications. I must also have missed their endorsement of using online applications for vaccine exemptions as a revenue generator (as was reported on RI not long ago).
"The truth is that there are thousands of pediatricians and perhaps millions of parents who want to deviate from the schedule but give kids shots, too."
And the sad truth is that there are pediatricians like Jay Gordon who preach against vaccines (except for the few they reluctantly give when parents insist), and who write articles detailing how to sneak around school vaccine requirements and thus place their kids and classmates at risk:
Science Mom: I’m not “sitting idly” on anything. I work. And do required CME and much more. But you’re right about my enjoying the dig at Dr. Hickie.
Todd: Ya’ got me! The schedule for the Hep B and polio vaccines is “whatever” according to the new CDC guidelines. I forgot that. But did see the “Vaccine” article discussing different responses to vaccines depending on the time of day. Fascinating stuff!
Todd, I count on you for sensible, cogent posts. The one above is not.
Narad, you imply that I’d need an additional vaccine—rabies—to head over to AoA. Firstly, I disagree with lots of their ideas—many people there are genuinely anti-vax and I’m not. Secondly, the frothing around here is mighty impressive too.
Lawrence, you’re wrong. Read the law and the CDHP FAQ page.
Dangerous Bacon, if you’re implying that I have "online applications for vaccine exemptions as a revenue generator” you’re, how shall I say it, full of feces. Good to see that no matter how long I stay away you still feel no obligation to be truthful.
By the way, #vaccineswork
Exactly how I am wrong? Children need only to be up to date before they enter kindergarten.....
If a child is starting school soon, they must receive every vaccine on the schedule as soon as they can. Obviously, one can't get a DTaP and then another two weeks later, but a child must get DtaP, polio, MMR, Varivax, right away. No flexibility. Medically, I think that's less safe than alternative paths. Proof?? No.
Darn! My post disappeared! A child has to get all vaccines possible before starting the "checkpoint" grades. No flexibility for entry to California schools.
Orac Says: "It’s hard for me to believe that it’s been approximately 16 years since I first discovered that there was such a thing as antivaccinationists."
OMG, what does one get an old friend and adversary for a 16 year anniversary??
And then . . . Post #30 reappears. Sorry for the duplication.
@Vince Ianelli-- I can direct vaccine hesitant patents to some vaccine materials on the AAP websites, but I have nothing from the AAP saying Gordon, Sears and Thomas are FOS. Until the AAP does that, they have no right to be critical of how I run my practice concerning vaccines.
Jay Gordon: "Dangerous Bacon, if you’re implying that I have “online applications for vaccine exemptions as a revenue generator” you’re, how shall I say it, full of feces. Good to see that no matter how long I stay away you still feel no obligation to be truthful."
I was referring to Bob Sears. You know, the disease-enabling pediatrician who you praised for his terrific explanation of California's new vaccine law, and whose medical exemption-granting was reported here:
By the way, Jay, how much do you charge parents for a medical exemption letter? Is an office visit mandatory (to discuss those myriad conditions you listed in your article as potentially justifying exemption), or would a telephone call or filling out an online form suffice?
*I'm curious about a statement in your article suggesting you wouldn't rule out a history of a "severe" vaccine reaction in grandparents, aunts, uncles or cousins as justifying a vaccine exemption. And how do you define a "severe" reaction?
Thanks in advance.
Dangerous Bacon--It did sound like you were speaking about me.
I don't charge for a medical exemption letter but I do insist that the child is an ongoing patient who is getting annual exams in my office. And, yes, I believe there are "myriad conditions" which qualify for a medical exemption. Each discussion is different but, as you have suggested, I listen to parents very closely.
If you ever want to communicate, Orac has my email address.
Have a great long weekend.
I know Jay's wrong in one dimension. California law has never required "every vaccine on the schedule" for kindergarten entry.
Note the vaccines omitted:
No rotavirus vaccine
No HIB vaccine (remember, we are talking kindergarten here)
No Pneumococcal vaccine
No influenza vaccine
No Hepatitis A vaccine
Forgot to put the source in.
So Jay: does that mean that if a parent whose child/children have not been your patients contacts your office to request a vaccine medical exemption letter, you insist they get an "annual exam" first - or is your exemption-writing limited only to patients who have first been in to see you on other matters? And while I hate to repeat myself, can you clarify if you would in fact accept parental concern about a "severe" vaccine reaction in Aunt Miranda as a valid reason to exempt little Bobby from receiving any vaccines? And how do you define a "severe" reaction?
I hope you will communicate a response. No e-mail is necessary.
By the way, to paraphrase Dr. Jay - it's good to see that no matter how often he visits RI, he's still capable of bemoaning a perceived lack of civility here, while flinging his own brand of invective (or feces, if you prefer). :)
Liz, thanks for the clarification. I meant every vaccine on the schedule appropriate for the grade level being entered.
Dangerous Bacon, I am accepting new patients and you're correct in that it's not easy in this new vaccine climate to discern who qualifies for a medical exemption. And I will look hard at "Aunt Miranda." Many doctors disagree. Sorry about the feces comment.
Dr. Hickie, you sound angry at Dr. Iannelli! I don't think he was pointing a finger specifically at you. Just commenting on how many pediatricians feel forced to have short office visits because of economic constraints. I don't know that you're one of those. I am very lucky to be able to schedule an hour for each checkup.
Dorit Reiss is the first commentator agian! Her provaccine propaganda radar sweeps the world-wide web with astounding alacrity.
Jay is correct that a student, to be admitted to school at any age, must have the following vaccines before admission to school:
Diphtheria,Tetanus, and Pertussis (DTaP), at least one dose, no earlier than 8 weeks before admission to school (otherwise the second dose is required)
Polio (OPV or IPV) at least one dose, no earlier than 10 weeks before admission to school (otherwise the second dose is required),
Hepatitis B, at least one dose, no earlier than 2 months before admission to school (otherwise the second dose is required),
Measles, Mumps, and Rubella (MMR) at least one dose, given no earlier than 3 months before admission (otherwise the second dose is required).
Varicella (Chickenpox) at least one dose, given no earlier than 3 months before admission (otherwise the second dose is required).
The language in the ruling is complicated, and I think the source, from the CADP Immunization Department, has not been updated since July 2015 (it still references PBEs)
The point is, SB277 was signed into law more than a year ago. Parents Have had a long time to get their kids immunized. Even the single dose of these vaccines don't have to be given on a single day. Parents are free to work out a delayed vaccination schedule that's in compliance with the laws and regulations.
RH@40: Or Dorit knows what time Orac usually posts. It's not exactly a secret. Or rocket science.
<a href=http://www.petrie-dish.com/?p=279<Here is an updated retention function for the Mitkus paper that is more accurate. The retention function in the original Mitkus paper used the highly soluble aluminum citrate to measure the elimination kinetics.
In light of this more accurate retention function, it is easy to see that the aluminum levels remain above the MRL for 190 days in infants under the extant CDC immunization schedule.
Here is an updated retention function...[hyperlink fail]
I'll take that as a "no."
And if parents had been vaccinating their precious snowflakes all along, even on a very delayed schedule, they still would have been fine. Also what Liz Ditz said.
So, it's late Friday afternoon here and I'm finishing a 10-yr-old check-up with a really nice smart boy due for another Varivax shot. He's got some reservations, to say the least. I tell him that after this shot almost every kid says just three words (I always say, "Is that it?") and he interrupts me and says, "I know what they say: Ho-Ly Crap!" I love it. Pediatrics is a very, very good job.
Narad, that is a "no."
That's not how it works here. You make a claim, YOU stump up the evidence.
“There may be good reasons why pediatricians should not care for children whose parents refuse immunizations. However, neither a breakdown in the physician–patient relationship nor the risks to other children in the waiting room are good reasons to do so.”
Are they serious?
JustaTech: "Or Dorit knows what time Orac usually posts. It’s not exactly a secret. Or rocket science."
Here on the American west coast I have seen posts from RI and SBM come live late in the evening. Obviously, Mr. Hayes does not comprehend who "time zones" work.
You can also sign up to be notified of new posts by e-mail. See the nifty little checkboxes below. :-)
If one checks both "Notify me of follow-up comments by email" and "Notify me of followup comments via E-mail," does one get two notifications?
There are those belt-and-suspenders types, after all.
Stop the presses...Jay Gordon does CME!!!. ....And so does every doctor I know who wants to keep their state license. Please regale us next about how you inhale O2 and exhale CO2 as part of your oh-so-disciplined pediatrician regimen, Jay.
Hi, Fendlesworth. Did you get lost?
coughthe highly soluble aluminum citrate
Take your O/T clown show and crawl back up Dan Steinberg's arse where you came from.
I'm reminded that I noticed someone at AoA trotting out the "thimerosal sinks to the bottom of the vial and they don't shake it enough" line today.
No doubt Fendlesworth (who is commenting as "Narad") has set this misunderstanding straight by now.
Dr. Hickie, why are you angry? You're probably a successful doctor with a nice practice and you get to take care of kids all day. Why the hair trigger temper?
Julian, decades and decades of an unethical relationship. Too many links and this will be caught in moderation for a while.
"The Academy got caught up in greed"
Take a look at the AAP 2016 Annual Report, too
Whenever the "good" Doctor Gordon drops by, he gets a ration of $#!+ for his anti-vax teachings. It is well and good that this is so.
But there is a whole heapin' helpin' of quackery on his web site not related to vaccines.
At http://drjaygordon.com , I read this on ear infections (gods of html, protect me from this lack of preview) -
For colds -
Anxiety or depression got ya down? Jay has that covered
Your kid got ADHD? Learn to cook.
You say your kid is bi-polar? Jay has some advice.
Of course, excrement occurs, and you need a well stocked first aid kit.
Of course, I'm not mentioning anything about immunizations.
Aww, why not? About the flu shot, Jay drops this gem -
The flu shot only protects against the flu?!? I never would have thunk such a thing. Who says Jay doesn't understand vaccines?
This is hard thing to prove. It is true that Thimerosal has a density of 2.51g/cm³, but it also has the highly polar carboxylate ion. Whether the Van der Waal's forces are enough to keep it perfectly homogenous is not easily discernable.
Perhaps you can set the record straight.
# 10 Narad
Laura Hayes, of course, does not miss this opportunity to bring the batsh*t crazy:
Well yes, but one has to admire her ability to write a sentence. That last sentence you quote is 98 words long and coherent. Perhaps batshi*t crazy but coherent. Most university students today cannot do this even if sane. I blame the lack of Latin in the schools.
"This is a hard thing ...". Not.
Given that thimerosal is soluble, not dispersable or suspendable but soluble, in water at a ratio of about 1:1 by mass (i.e. 50% w/w) at 20°C, there is zero possibility that the amount in any vaccine (0.01% w/w, typically) is not going to come out of solution and sink to the bottom.
It is true that thimerosal in fully soluble in water at pH 7, but in a slightly acidic solution, it precipatates and decomposes.¹ Thimerosal is also destabalized by sunlight, Boric acid³, and NaCl.
You might expect a Hg density gradient in aqueous solutions aged for long period of time, but any EtHg liberated from thimerosal in a vaccine formulation would no doubt bond with the thiol side-chains of the proteins.²
But if this were to happen, we would have an amount of relatively high-density proteins in the solution that may form a gradient.
I think that Gorski should go down to the Chem department and find out. There is an AoA article that says an experiment was conducted where a draw from the bottom of a multi-dose vial contained 27μg's of Hg. This was after letting it settle for only 20 minutes.
But it's only 1:8 soluble in ethanol by volume.
How much water is in a vaccine?
Edit: One gram Thimerosal per 8mL Ethanol.
If you don't know that, then it is safe to conclude you know nothing about vaccines.
Do you know?
Well, it's only a range of 18 orders of magnitude. What could go wrong?
You're responding to "Fendlesworth," "Ted Striker," "Avocado Aficionado," "monica," "Tenfold Shrew," "Stradlater," "animal support," "Animal Support," "Under Protest," "Annabel Lee," "Concerned," "Under the Bridge," etc.
I've been awfully busy lately, but I have been wondering whether get around to laying down the shіthammer at AoA over the impersonation.
There are, however, multiple approaches. One common theme, though, is that Typepad has declared a block on Tor exit nodes and common proxies, and it does a rather good job at it, based on a bit of probing. Private VPNs, I don't know, but this is pretty clearly a low-rent operation.
The most straightforward angle is thus the telltale Wisconsin netblock.* "Internal" cross-checking of keys would be trivial.
* No, I haven't been interested enough to search the DNSBLs.
Why don't you just ask me to stop?
Haven't used these names: animal support, Animal Support, Under Protest, Under the Bridge
And definitely not this name: Concerned
Then tell us. What is the water content of Alfuria? You don't know, you are just posturing.
^ "whether to get around"
I'll just take that as a "yes," given the allusion to vdW forces.
Robert Hayes at #71.
Then why'd you even bother going through the two-post motions of "I'm not Fendlesworth!"?
Jay Gordon @30
What kind of nonsense is this? Are you really a pediatrician? No flexibility? The checkpoints are kindergarden and 7th grade. The vaccines required for kindergarden entry have a window starting at four years of age.
The only reason a child would have to squeeze them in right before kindergarden entry is if the parents decided to skip them when the child turned four! In fact, a parent could, if they were concerned about a lot of injections at once, choose to do some of the vaccines at 4 years old, and some at 5, and still make that checkpoint.
Is your statement here perhaps influenced by the fact that you aren’t counseling parents about the recommended schedule, and now they’re upset because they’ve lost the flexible window? That’s on you, not on the CDC or the State of CA.
The next checkpoint - which is pretty much just for TDaP – again, unless you skipped all the other vaccine earlier! – is at 7th grade (and, no, Jay, the older kids are not getting DTaP as you posted). There are seven years between the two checkpoints. There is plenty of time to choose when to give your child another dose of protection against pertussis (tetanus and diphtheria being a bonus along with it).
The flexibility has always been there. You need to start telling the parents of your patients about it.
Apologies for the excess bold, but maybe it will get Dr Jay to take note.
In 1932 Morris S. Kharasch filed his second patent for Merthiolate (Thimerosal). In this patent, he details how Thimerosal destabilizes in aqueous solution forming dithiocarboxyphenol, ethylmercury, and ethymercury hydroxide.
@Robert Hayes, your link in #77 is fascinating, but...
It doesn't constitute proof.
And you said "AoA article". I do not trust AoA. If they wrote that the sun rises in the east, I'd be outside with all sorts of instruments checking.
Julian, most so-preserved vaccines contain 0.01% thimerosal, which is approximately 50% mercury by mass, and for most a dose is 0.5 mL. A dose would therefore be expected to contain 50 µg of thimerosal, equivalent to about 25 µg of mercury.
Uh, wasn't thimerosal removed from most vaccines several years ago? Why are we having a discussion about it now? (Yes, I know that it's in multi-batch flu shots, but that's just ONE vaccine.)
It was removed in 2001 (except for multi-dose vial flu vaccines), but it is still a big antivax issue because stupidity is difficult to relinquish.
It's sort of like saying people should not drink alcoholic beverages, because Prohibition has resulted in some booze containing rubbing alcohol.
He shouldn't have to you homophobic, scat-obsessed sick creep.
from the AoA article:
So by applying utterly irrelevant arithmetic to the results from a dubiously-performed test, somehow an "excess" of 8% gets explained as actually being 25%. Newflash, dolt. If every dose from a five dose vial contained exactly 25 µg of mercury, the fifth dose would contain 100% of the amount remaining in the vial. Is everyone at AoA that stupid?
^ I was thinking 5 dose vial, but they had a 10 dose vial for the test. Not that it changes the fact that the last dose contains 100% (ignoring overfill volume in the vial) of whatever is left.
Chemmomo at #75
Not quite correct.
For the 2016-2017 school year, incoming 7th graders (even those who had a Personal Belief Exemption filed before January 1 2016), and all students ages 7 to 17 entering California schools for the first time, must provide proof that they have received the following vaccines:
Diphtheria,Tetanus, and Pertussis (DTaP, DTP, DT, Tdap, or Td)—4 doses (3 doses OK if last dose was given on or after 2nd birthday); Tetanus, Diphtheria,and Pertussis (Tdap) —1 dose at 7th grade or out-of-state transfer admission at 8th–12th grades (1 dose on or after the 7th birthday)
Polio (OPV or IPV)—4 doses (3 doses OK if one was given on or after 2nd birthday)
Measles, Mumps, and Rubella (MMR)—1 dose for children below 7th grade; 2 doses required at 7th grade
Varicella (chickenpox) -- Admission at ages 7-12 years need 1 dose; ages 13-17 years need 2 doses)
The conditional entry provision for 7th grade is stricter than for kindergarten. In this case, previously unvaccinated 7th graders have to be up-to-date for age. But I repeat -- parents of unvaccinated kids in sixth grade in the 2015-2016 academic year have had adequate warning that their children would need to be up to date on all required vaccines. It's been 13 months, after all.
I agree. Still, most of the vaccines were already required for kindergarden unless you had a PBE. And, yes, the PBE parents have a had a whole year to get their children vaccinated, including everything they opted out of back before their child went to kindergarten.
But the TDaP for 7th grade was added for 2012. The children who were up to date for kindergarden back in 2009 do need their TDaP before starting 7th grade this year. And again, they’ve had plenty of time to get it – it’s not like the law says it must be just before you start the school year.
I don’t have much sympathy for the parents who need to catch their kids up due to their no-longer-valid PBEs.
And I have even less sympathy for Dr Jay complaining about how onerous it for those parents to get all the vaccines now - and oh no!as soon as possible - because he should never have been letting them believe it’s OK to skip the vaccines in the first place.
Liz's post is exactly the way I understand the requirements.
Dr Jay, if you understand the requirements, can you explain to me why you are complaining about a lack of flexibility? There's only a problem if you condone vaccine refusal, and have a lot of patients who need to catch up.
And the law did not take effect overnight - they've had enough time to schedule those catch up vaccines.
@ Julan Frost
That link was mainly directed at this claim made by Doug: there is zero possibility that the amount in any vaccine (0.01% w/w, typically) is not going to come out of solution and sink to the bottom.
Zero possibility is quite the overstatement considering the instability of Thimerosal®, the insolubility of ethylmercury, and the density of ethylmercury.
Sorry, was it too long for you? Too many words? Did anyone else find my comment lacking in sense or cogent points?
Here's the short version for you, Jay: your claim that there is "no" flexibility for parents is nonsense and shows your utter disregard for facts. There is quite a bit of flexibility, unless, of course, you happen to be one of those parents whom Jay has scared away from vaccination and now find yourself in a bit of a bind. But, as others noted, that's on you, Jay, and the parents, not the CDC, AAP, or the CA legislature.
Jay, part of why you're treated as you are, aside from your parroting of anti-vaccine talking points and pulling stuff out of your nethers rather than sticking to actual facts, is your smarmy, self-righteous tone. You cry that others treat you with a lack of civility, when you make little effort to be genuinely civil yourself. Sure, you couch your comments in language that avoids swearing, and you tend to avoid direct insults (with notable lapses now and again), but your prose is positively dripping with disdain for those you address in your rather round-about manner.
Is it so difficult to admit that you were completely wrong, without resorting to jibes at others or attempted rationalizations for your comments? Do you lack even the basic courage for that?
Thank you, Todd.
The flexibility for meeting the requirements has always been there – unless one deliberately chooses against it.
It's like getting a term paper assignment, choosing to wait to start until the day before it's due, and then complaining that the teacher didn't give you enough time to do the assignment.
@86 I have zero sympathy for any parent who deliberately endangers their child (barring legitimate medical reasons), by not getting the vaccine for diphtheria. One can only assume they get their jollies by picturing their child suffocating, or think that a tracheotomy is no big deal, being more "natural" than a vaccine. Perhaps the hope is for skin lesions they can treat with Black Salve?
I had a neighbor who "cured" his wife of diphtheria (back in the 30s) by painting her throat with turpentine. Sounds fun, right?
I will never, ever understand why people think VPDs are preferable to vaccines to help prevent them.
But, it's not facing the Zombie Autism caused by all Science and Medicine, so it's all good.
Well Ellie. All of the extant diptheria vaccines contain either aluminum phosphate or aluminum hydroxide. These are known neurotoxins. Perhaps these parents you speak of are intelligent enough to realize this.
@Doug and Julian Frost
Bacteriostatic action of such organomercuric compounds in the presence of serum is therefore largely prevented by competition of reactive groups on the serum proteins for the mercury. This presumably is the basis of the finding that the ‘activity of a mercurial antiseptic in serum is reduced to 0.33-0.0007 percent of its activity in saline¹.
-Maj. Gen. Douglas B. Kendrick MD
¹http://dr-king.com/docs/070824_CoMeDCitizenPetitionPart2.pdf [p 23]
Knowing that ethylmercury has a greater affinity for the thiol groups of cysteine than it does for the thiosalicylate moiety of thimerosal, one has to consider the solubility of egg albumin when theorizing whether or not Hg creates a density gradient in a multi-dose vial of Afluria®.
@Robert Hayes, your quote above says "presumably". So I'm sceptical. When I clicked on the link, a 447 page pdf opened. I'm not going to trawl my way through that.
“Thimerosal is a weak antibacterial agent that is rapidly broken down to products, including ethylmercury residues, which are neurotoxic.
David Seal: The case against thiomersal. Lancet
Now that the "Robert Hayes" has for the moment stopped negging the commentariat here, and has resorted to dumping copy-paste instead...
...One wonders how many link drops and italicized snippets it will take for The Fen to get down to detailing what actual medical issues thimerosal causes, and especially how their incidence corresponds to variations in thimerosal exposure.
1) Who the heck is "David Seal"? Is he a researcher, a medical practitioner, or just some bloke who wrote a letter?
2) Ethylmercury is not neurotoxic, methylmercury is.
"While the mercurial preservatives had good activity on initial addition, after storage of three, six or more months decreasingly less to negligible residual activity appeared to be left, indicating that the chemical was tied up by the protein of the biological or otherwise inactivated."
Engley: http://www.sarnet.org/lib/Engley%20Study%201956.pdf [p.205-206]
There is even a graph of Bactericidal Effect vs Time!
These quotes outline how Thimerosal disassociates in solution and bonds to the cysteine residues on proteins. I am not trying to demonstrate toxicity; that would be way easier.
This is just a continuation of refuting Doug's quote: "there is zero possibility that the amount in any vaccine (0.01% w/w, typically) is not going to come out of solution and sink to the bottom."
Well... Pearl-clutchy 'what ifs' serve as casual distraction, sure, but without reliable evidence of actual harm the appeal to speculation remains unconvincing.
If thimerosal is so toxic, how come the ups and downs of exposure to it (wether via vaccines, or topical antiseptics, or never seem to coincide with increase and decrease in incidence of whatever it is supposed to cause?
topical antiseptics, nasal sprays and whatnot never seem to...
(that'll learn me to remember to disable the touchpad).
I am just trying to defend the myth that the mercury in a vaccine could theoretically be distributed more towards the bottom of the vial. I have just shown that the ethylmercury moiety if Thimerosal does in fact spontaneously disassociate in solution. I have further shown that this same ethylmercury will bond to the cysteine residues of the protein (ovalbumin) contained in a flu vaccine. And what I am about to show you is this quote from the Alfuria® package insert: "Influenza Virus Vaccine for intramuscular injection, is a sterile, clear, colorless to slightly opalescent suspension with some sediment that resuspends upon shaking to form a homogeneous suspension."
So we have a situation where the ovalbumin-bound ethylmercury is concentrated on the bottom of the Alfuria® multi-dose vial.
The actual AAP position paper ( http://pediatrics.aappublications.org/content/early/2016/08/25/peds.201… ) states (as you noted in a longer citation earlier, Orac):
For these reasons, we believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines, a position that is shared by the American Medical Association and the Infectious Diseases Society of America and is currently the basis of a policy statement being developed by the AAP. There has also been greater recognition among pediatricians that delayed or incomplete vaccination schedules are probably responsible, at least in part, for the spread of measles in that outbreak.
First, I'm not sure why the AAP doesn't mention that the AAFP also adopted this position in 2015 ( with a much stronger wording and opinion than what the AAP says: http://www.aafp.org/news/health-of-the-public/20151012vaccineexempt.html ). It might be the AAP doesn't want to state the obvious--the AAP's severe lag relative to what the other major medical groups realized very well last year. That is what I suspect.
Second, regarding that last sentence about there being "greater recognition among pediatricians": last year David Tayloe, former AAP President spoke at the 2015 AMA convention when the AMA passed their resolution calling for an end to non-medical vaccine exemptions. Here is how Tayloe said it to the AMA ( as described by Dr. Sanjay Gupta at http://www.medpagetoday.com/MeetingCoverage/AMA/52000 ):
"The former president of the AAP, David T. Tayloe, MD, stepped up to the mic and reminded everyone that the AAP policy calls for no non-medical exemptions whatsoever. "The AMA does not need to leave a loophole in its policy for the likes of Jenny McCarthy, Bob Sears, etc ... Our vaccines are extremely safe, and children need to be immunized at 90% or more to achieve herd immunity, and we can't do this with choice."
Tayloe's words were an outright lie to the AMA attendees. There was *no* AAP policy at that time (otherwise why release this position paper?), and the hypocrisy of Tayloe to tell the AMA not to leave a "loophole" for Bob Sears is astounding, given that the AAP gives Sears the largest loophole around--AAP membership and FAAP status. Again, I think the AAP is trying to look good with this and still is not seriously battling anti-vaccinationism (and if you read their statement, it says ending non-medical vaccine exemptions is "currently the basis of a policy statement being developed by the AAP. " --which means it still is not AAP policy).
Oh, and Jay Gordon, you might think I'm angry, but better words would be disgusted and ashamed regarding your continued license to practice as a pediatrician. You don't seem to give a damn that two more infants have died from pertussis in California thanks to the AV nonsense you spew. But then again, given that you can't even diagnose HIV in a child with severe FTT born to a mom with HIV (the type of question you should have been able to answer on a test even in year 1 or 2 or medical school) tells me you are not competent to be a pediatrician. You should have lost your license when you didn't test that girl for HIV and she died shortly therafter. If you aren't bright enough to get that HIV is transmitted during birth, why should we ever expect you to get vaccines?
While disregarding the curiously selective bolding, It's my understanding that the Alfuria description applies both to single-dose vials (that do not contain thimerosal) as well as multi-dose vials (that do). Therefore, I'm not entirely convinced the mentioned sediment is ovalbumin-bound ethylmercury as The Fen claims.
Then there is the fact that the multi-dose vial is shaken vigorously immediately before administration. Making the hypothetical boogeyman scenario even more of a non-issue.
I'd keep working on that "closing argument".
Speaking as a layperson, I am not surprised to hear claims that Thimerosal can settle to the bottom of a vial. It's a suspension. Even if there weren't some mysterious albumin binding phenomenon, I'd still expect a gradient to appear. I've always believed this was the reason nurses shake the container before drawing out a dose. Heck, OTC liquid medicines and even a lot of food products always have a warning to shake the bottle before measuring, due to settling, so I would think this would be something anyone would realize. Apparently it is news to the antivaxxers.
Although I'm late very late to this party and severely jet-lagged, I want to note these points before I fall into fitful sleep at an inappropriate hour in my own time zone:
1. This discussion seems to have neglected some of the problems associated with medical exemptions. A "bad reaction" to a vaccine is, in my view, one that doesn't stimulate an appropriate immune response, but many parents--and perhaps some or even many pediatricians--might believe that events such as, say, benign febrile seizures following vaccination might support a medical exemption from vaccination, despite that the evidence suggests that such seizures are genetically determined and generally follow febrile episodes that are not temporally associated with vaccination. What guidance is offered regarding what constitutes a valid claim for a medical exemption from vaccination?
2. I don't mean to rag on Doctor Jay Gordon (well, this time--because I learned by visiting his web site that, to Jay's credit, he doesn't write vaccine exemptions for drive-by parents) but I wonder if he can answer this question: Do you think that a child who has suffered a febrile seizure following vaccination--or who has a first-degree relative who has suffered such a seizure following vaccination--merits a medical exemption from vaccination given that ca. 5% of children experience febrile seizures early in life? If so, why?
3. The people who are associated with Wakefield's Quaxxed are even loonier than I thought:
Yes, a "medical journalist" is either so delusional that he thinks that that vaccine "was only tested for four days" or he's lying through his teeth. He doesn't even need PubMed here; Google will do. (Sheesh. I think he's lying--but I also think he's ignorant.)
You're right. It's a myth. Therefore there is no need for you to defend the myth.
Her latest entry (oddly styled as an "Op-Ed") is just sad. I'm surprised that AoA even ran it; it's a pure, stale antivaccine screed.
Hey, the photo of the RV has a different 'x' painted red.
I still think the AAP is not serious even in what they are saying in their position paper. From the AAP position paper (and the last sentence of your first quote from it):
For these reasons, we believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines, a position that is shared by the American Medical Association and the Infectious Diseases Society of America and is currently the basis of a policy statement being developed by the AAP.
Well, that sounds good. Note, however, that the AAP says it "is currently the basis of a policy statement being developed by the AAP". So this is not yet a policy statement and what that means is the AAP will presumably decide on this at their annual meeting in San Francisco in October. It might not pass a vote, but with this "position" paper, the AAP can still claim "toughness". Contrast this to the AMA which actually passed policy in 2015 stating they wish to see non-medical vaccine exemptions ended.
I'm also puzzled as to why the AAP didn't mention that the AAFO (American Academy of Family Physicians) passed policy endorsing ending non-medical vaccine exemptions in 2015 ( http://www.aafp.org/news/health-of-the-public/20151012vaccineexempt.html ), with the president of the AAFP coming out much more strongly on this than anyone from the AAP:
"In the last few years, we've seen more and more people recklessly forgo vaccinations," AAFP President Wanda Filer, M.D., M.B.A., of York, Pa., said in a statement. "Some people even refuse to vaccinate their children. In doing so, they put everyone around them at risk.
"Enough is enough. Science has settled this issue. Not only are vaccines safe, they save lives."
I suspect the AAP does not mention this in their position paper because it makes the AAP look weak on vaccines, which the AAP is.
Finally, there is outright lying in what the AAP told AMA members at last year's AMA annual convention regarding non-medical vaccine exemptions--as reported by Dr. Sanjay Gupta ( http://www.medpagetoday.com/MeetingCoverage/AMA/52000 ):
The former president of the AAP, David T. Tayloe, MD, stepped up to the mic and reminded everyone that the AAP policy calls for no non-medical exemptions whatsoever. "The AMA does not need to leave a loophole in its policy for the likes of Jenny McCarthy, Bob Sears, etc ... Our vaccines are extremely safe, and children need to be immunized at 90% or more to achieve herd immunity, and we can't do this with choice."
Dr. Tayloe flat out fibbed to the AMA when he cited non-existent AAP policy. Furthermore, it is galling the Tayloe (and the AAP) criticize the AMA for "leaving a loophole" for Bob Sears when Sears is using the FAAP monicker and makes no claims of AMA membership. The gigantic "loophole" left by the AAP for Sears is only exceeded by the "loophole" of the California medical board refusing to discipline Sears.
Again, the AAP is trying more to publicly look good than actually get into the battle against anti-vaccinationism. I'd really like to know how many more VPD outbreaks will be needed before they are going to get off the sidelines on this.
I have to say the comments following Hayes's call for the banning of vaccines at AoA strike me as nearly ideal for illustrating to someone who was vaccine hesitant that these people are more than a few marbles short of a picnic.
This one, in particular, is worthy of Th—h2.
@Robert Hayes #105
That was quite the effort, but everything that you have just shown can be summed up in just this one experiment: Interaction of thimerosal with proteins—ethylmercury adduct formation of human serum albumin and β-lactoglobulin A.
In this experiment, the researches used lquid chromatography, inductively coupled plasma mass spectrometry, and electrospray mass spectrometry to determine the quantity and quality of ethylmercury-protein adducts after a one hour incubation of Thimerosal with human serum albumin and β-lactoglobulin A. Here are some relevant quotes from the paper:
Robert Hayes' first point is corroborated by these chemists.
Robert Hayes' second point is corroborated by these chemists.
Robert Hayes' third point is suggested by these results; the LC + ICP-MS analysis is the smoking gun. It only took one hour for all of the Thimerosal to covalently bond with all of the proteins.
Le Châtelier's principle.
For the latter half of the experiment, the experimenters used trypsin to digest (cleave) the protiens in order to determine the exact bonding site for ethymercury. It is worth mentioning that both serum albumin and β-lactoglobulin A have only one free thiol group. What Robert Hayes didn't do, though this is trivial, is to prove that chicken egg ovalbumin has at least one free thiol group. You simply cannot just look at the protein sequence for cysteine because cysteine often forms disulfide bridges in proteins, and these disulfide bridges will not bind mercury.
The vaccine he babbles about contains less than one microgram of egg albumin per dose, whereas it contains nominally 50 µg of thimerosal per dose.
This is someone who seems to have no quantitative idea of the water content of vaccines.
Julian @ 97 - have a look at the page, near the end, that lists the signatories to the petition - the Geiers, what's his name the nasty engineer, et al
As it turns out, ovalbumin does have 4 reactive thiol groups:
Thiol and Disulphide Contents of Hen Ovalbumin
Thiol groups were determined by reaction with methylene blue and subsequent titration with glutathione. They were also determined by methylcarboxylation of the thiol groups with radiolabeled iodoacetic acid followed by tryptic digestion, liquid chromatography, and electrophoresis.
These two analytical approaches were in perfect agreement with each other. All of the ovalbumin came from the eggs of the White Leghorn hen.
Ah good old Thimerosal, or Thiomerosal, or Thiomersalate, or Mercurothiolate, or Sodium ethylmercurithiosalicylate
Thiomersal was formerly used in cosmetics and topical medications (meaning all over the place) but is today removed from most products.* According to the European Union cosmetic directive thiomersal is allowed for use with eye products only.
*In the US and Europe, "Outside North America and Europe, many vaccines contain thiomersal" and presumably many other products, yet the US and Europe still lead in the Autism rates**
** Or they did last time I looked.
You cannot forget about the influenza viral capsid proteins in the vaccine. In the 2009 H1N1 vaccine (Novartis), we have 18.8μg of viral hemagglutinin, neuraminidase, and necucleoprotein per dose¹. These are the viral antigens, hence the only ones commonly measured, but there are 6 other proteins² that make up H1N1.
So there is more than 18.8μg of protein to react with the 24.5μg of mercury in each vaccine.
¹Label-free mass spectrometry-based quantification of hemagglutinin and neuraminidase in influenza virus preparations and vaccines [table 6]
Hey, that's familiar.
This Western Blot shows the relative proportions of the 9 influenza proteins.
Geez, another sock to have a conversation with himself?
I'm going to hold off on killfilling this one because the ineptness is already cracking me up.
Well Doug, can you come up with some numbers?
C'mon, Travis, you can't give up the act that easily. Tell everybody about the "western blot."
Yes. Absolutely. It is 97.6217648%, ±5% water.
Someone else will have to verify this for me, but IIRC, in 1923 in the Weimar Republic, you could buy two dozen Fendles for a pfennig.
At least that one could manage to stay on the sidewalk for a few paces, instead of staggering into oncoming traffic.
I suggest just skipping to the epilogue of Fassbinder's Berlin Alexanderplatz.
You are a liar. Anything with a 5% variance wouldn't have so many significant figures.
So much for amusement value.
Narad, some day I'll get around to watching the second half of Alexanderplatz. I saw the first half in a theatre many years ago, but didn't go back for day two. I was too distracted with other things at the time.
Some people attach special significance to 7, though I don't.
This is something I never could have imagined asking myself, but I don't think the epilogue has any spoilers.
The only reason that I posted the Western Blot is to show that the matrix protein (M1) would contribute a significant amount of protein to the 18.8μg from hemagglutinin (HA), neuraminidase (NA), and necucleoprotein (NP) per dose. This is enough protein to bind a significant amount of ethylmercury in the vaccine.
Words have meaning, some more than others.
In the Hepatitis B vaccine, Thimerosal is decomposed to 76.2% [table 2] of it's original value after 2-4 years.
Reversed-phase high-performance liquid chromatography versus spectrophotometric assay for thimerosal in Cuban recombinant hepatitis B vaccine
In this study, the Hep B vaccine is centrifuged and the supernatant is eluted through a reverse-phase chromatography column. Thimerosals' degradation products, thiosalicylate and dithiosalicylate, are found in the supernatant but ethylmercury is not. [fig 1]
If the ethylmercury could not be found in the supernatant, then it must have been in the sediment (pellet). This study indicates that after 2-4 years of storage, ~25% of the vaccines' initial mercury concentration is insoluble.
Only for my amusement (because I know it is Fendelsworth/Travis):
Please tell us which vaccine the present American pediatric vaccine schedule is only available with thimerosal. Do not mention influenza vaccines because three are single dose types that do not have thimerosal. Also the Tripedia DTaP vaccine has not been sold for five years.
I'll repeat my question to the previous Fen, I'm hoping that with its rapid rate of metamorphosis eventually one generation will have evolved some intelligence.
Given how terribly toxic you claim thimerosal is, what conditions does it cause and how does the instance of these correlate with waxing and waning thimerosal exposure?
It causes clinical or subclinical mercury poisoning. People have died from Thimerosal exposure.
Thimerosal increases mercury poisoning in a dose-dependent manner.
@Lars Ørnsted #141:
Hey Travis, have you worked out that whole ethyl mercury demethylation problem yet?
Well, since I've been putting these here . . . . AoA – The Land Where Old-School Trolling Can't Be Distinguished from Regular Comments:
You be the judge!
Five quatloos on the standard omphalocele item.
You really need instances of Thimerosal deaths? There are hundereds.
Sure, dude. Just list the PubMed IDs of the case reports. In the mean time can you tell us which vaccine on the present American pediatric schedule is only available with thimerosal?
Remember to not mention influenza because there are three single dose versions without thimerosal. Also do not mention the DTaP vaccine that has not been manufactured for five years.
Immunization Safety Review: Thimerosal - Containing Vaccines and Neurodevelopmental Disorders [page 42]
Fork over the 5 quatloos Narad.
So, Travis, which vaccines on the present American pediatric schedule are "topical applications of 0.1% tincture of Thimerosal"?
Also, how is "ten" equivalent to "hundreds"?
Lars @148: So 10 babies whose intestines were hanging outside of their abdomens were painted with a Thimerosal-based substance and then died, and 3 of those babies had high mercury in their organs.
So 1) This can be a fatal birth defect, even now in the 21st century.
2) This happened in or before 1977.
3) Your quote does not give us any idea of the amount of tincture of Thimerosal that was used on these babies, or their weights so that we could calculate dose.
4) This is a topical application, not a vaccine.
5) Is this a treatment that is still in use?
6) This quote does not say that the deaths were caused by the Thimerosal. It doesn't even say what kind of mercury was found in the organs.
In total: not completely off topic, but hardly the slam-dunk you were expecting.
Does this mean that I guessed correctly, or did Fondleswith merely run with it? (Bonus question: What's the base CFR for this condition? Hint: Add "survivors" to the search.)
Oh, and did it actually barf up the paper?
Again, Travis, which vaccines on the present American pediatric schedule are "an otic solution containing 0.1% thimerosal" that are administered topically in that manner that it could be swallowed in quantities up to 1.2 liters, or contain " 510 mg of thimerosal"?
You are really reaching. And you have yet to tell us why this is an issue for vaccines in the present American pediatric schedule.
Lars @154: So compounds with a thousand times more thimerosal than intended are not safe. Good to know. There are lots of compounds you should not use at 1000X concentration.
Again, what does this have to do with modern vaccines?
Intestinal methylation of Hg is another explanation for the data obtained in the Rodriguez study. After all:
It is not unreasonable to assume that bilary Hg could be methylated by bacteria and readsorbed.
Yep. Fendelsworth just gave himself away unequivocally. The ban hammer has been brought down.
Sorry. I was away from the blog for several hours after approving his first comment, which seemed benign enough.
Heh: 204 g and 3 kg.
P.S. Those thiol-bound groups are inert, dipshіt.
P.P.S. You're really cluttering up my killfile.
You're going to get nowhere without IP-based blocking. Start with /32's, and go from there. I don't think that this is a case in which there's going to be much collateral damage.
I've been using various forms of blocking, including IP-based and can tell you that what you are proposing probably won't help much. I won't say much more than that publicly.
And another Fendlesworth IP: 188.8.131.52
Oh, I have many, many more than that, a veritable collection. Unfortunately, I'm sure I'm missing some, given that I didn't start collecting them until well into the Fendlesworth onslaught. :-)
Nor would I expect you to. I can count the inroads on one hand, though. Wetware is probably the most efficient option in any event; I rarely put things in the mod queue inadvertently.
Just helping you add to your collection. ;D