Vaccines: Questions & Answers with Paul Offit
At the tender age of 5, Paul Offit, a native of Baltimore, spent several months in 1956 in the city’s Kernan Hospital for Crippled Children while recovering from a clubfoot operation. Housed with him were around 20 children crippled from polio, a debilitating and paralyzing disease for which there was a new vaccine, but one which had not yet reached popular use.
Parents of the children in the hospital, which has been renamed and is now a part of the University of Maryland Rehabilitation & Orthopaedic Institute, were only allowed to visit for one hour each week on Sunday. Offit’s mother was pregnant at the time and unable to visit him, and he can vividly recall staring out the window, awaiting his father’s weekly return.
This distressing childhood experience would remain with Offit, and guide and influence his future work in pediatrics and pediatric infectious diseases.
Offit, the Maurice R. Hilleman Professor of Vaccinology and a professor of pediatrics at the Perelman School of Medicine, and a professor of pediatrics in the Division of Infectious Diseases at the Children’s Hospital of Philadelphia (CHOP), is one of the world’s leading experts on vaccines, virology, and immunology.
He is an unabashed advocate of vaccines and their safety, and the co-creator of the RotaTeq vaccine, which prevents the rotavirus, a disease common in infants and young children in the developing world that can cause severe diarrhea, vomiting, fever, abdominal pain, and death.
In order to disseminate factual information about vaccines to the public and media, Offit co-founded the Vaccine Education Center at CHOP in 2000. He has also authored more than half a dozen books to dispel falsehoods about vaccines, including “Deadly Choices: How the Anti-Vaccine Movement Threatens Us All,” “Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure,” and “Vaccines and Your Child: Separating Facts from Fiction,” and is currently teaching the massive open online course “Vaccines,” which is running on Coursera and discusses issues germane to vaccines and vaccine safety.
“The motivation for educating [the public] about vaccines and vaccine safety is because I don’t want to have to watch children come in to our hospital and suffer and die from diseases that are preventable,” he says.
The Current sat down with Offit in CHOP’s Abramson Research Building to discuss vaccines, vaccine education and safety, the anti-vaccine movement, vaccines and religion, and the importance of herd immunity.
Q: Do you remember much from your time in the hospital as a 5-year-old?
A: Yes. In fact, I was a medical student at the University of Maryland and there was a rotation where we had to actually go to the building where I was housed in a polio ward following a clubfoot repair. It wasn’t a polio ward anymore, obviously; this was in the late 1970s. It was an office, actually. The room where I had stayed was an office, and I remember walking in there and being overwhelmed by emotions, just fighting back tears. I guess because I’m taller, the windows were all lower than I remember. My bed was right next to a big window and you could see through to the front door, so you could see whether anyone was coming. My father visited me one hour a week on Sundays from 2 to 3, and I used to just stare out that window. I remember just walking up to that window as a medical student and staring out that window and seeing the front door and being overwhelmed emotionally.
Q: You received your undergraduate degree from Tufts University in Massachusetts. Did you know you wanted to be a doctor when you entered Tufts?
A: Yes, I think I wanted to be a doctor even as a child, maybe because of that experience in the polio ward. I had a number of hospitalizations all when I was 5. The clubfoot repair and the long-term rehabilitation stay was one, but I also ruptured my spleen from a traumatic event and had a splenectomy when I was 5.
Q: You mentioned in a podcast that while you were an intern at the Children’s Hospital of Pittsburgh, a child died from a rotavirus infection. Did that experience play a role in compelling your work on developing a rotavirus vaccine?
A: It was always in my head. That image of the child dying, this otherwise healthy 8- or 9-month-old little girl who had acute diarrhea and vomiting and fever that caused her to be severely dehydrated by the time she got to us, and it was all within a day. By the time she got to us, it was really too late to save her. I just remember having to tell the mother, who was waiting outside at the time when we tried to resuscitate her, that her child had died. There’s no moment worse than that, so that always stuck with me. When I got to Children’s Hospital of Philadelphia as a fellow, there were a number of research opportunities, one of which was to do research on rotavirus. I guess that was part of the draw.
Q: Does medical school provide any training on how to tell a mother or father that their child has passed away?
A: No. What you have is you have 26- and 27- and 28-year-old people who have recently graduated from medical school and now are interns and residents who generally don’t have children who are asked to tell a mother or parents that their child has died. We got no training for that, other than just trying to be a human being.
Q: Am I correct that the middle of the 20th century was somewhat of a golden era for vaccine research and development?
A: Yes. You had a polio vaccine in 1955; you had a measles vaccine in ’63; you had a mumps vaccine in ’67; you had a German measles/rubella vaccine in ’69. There were a series of vaccines.
Q: Your first book was titled, ‘The Cutter Incident: How America’s First Polio Vaccine Led to Today’s Growing Vaccine Crisis.’ Did people have reservations about the polio vaccine even though it prevented such a horrible disease?
A: Five companies stepped forward to make a polio vaccine in 1955. One of them made it badly. Instead of injecting children with inactivated poliovirus to induce a protective immune response, they inadvertently inoculated about 120,000 children with live, fully virulent poliovirus. As a consequence, about 40,000 children developed abortive or short-lived polio, about 200 were permanently paralyzed, and 10 were killed. I think it’s one of the worst, if not the worst, biological disaster in this country’s history. That people would have been hesitant to get a polio vaccine after that made perfect sense because we hadn’t yet quite mastered the ability to make sure that we completely killed every poliovirus particle in that vaccine, so the vaccine was temporary suspended for a few weeks in May of 1955. The polio vaccine program was suspended in the United States, so that certainly scared people, reasonably.
Q: What would a whooping cough, or measles, or mumps, or rubella outbreak look like today?
A: Measles is probably the best indicator of the strength of an immunization program because it’s an excellent vaccine. We basically eliminated measles from the United States by the year 2000. But, it’s also a highly contagious disease, so you need high immunization levels in order to keep the virus from spreading, so-called herd immunity. When herd immunity starts to erode, that’s often the first virus to come back. The outbreak in Disneyland [in late 2014 to April 2015] involved about 150 people and spread to seven states. About 14 percent of those who got measles were hospitalized, many with measles pneumonia. Fortunately there were not deaths, but there could have been.
Q: Diseases such as these can be deadly without vaccination?
A: Before vaccines, pertussis or whooping cough killed about 8,000 people in this country every year. Diphtheria was probably the most common killer of teenagers in the United States. Polio would paralyze tens of thousands of children, and kill about 1,500-2,000 every year. Pneumococcus would cause tens of thousands of children to be hospitalized with diseases like meningitis and pneumonia and bloodstream infections. Even chicken pox would cause 10,000 children to be hospitalized and between 70-100 to die every year. These are diseases worth preventing.
Q: You helped launch the Vaccine Education Center at CHOP in 2000. What were your reasons for establishing the Center?
A: I worked on a team at the Children’s Hospital of Philadelphia with Fred Clark and Stanley Plotkin. The three of us worked together to try and create a rotavirus vaccine. It was a 26-year effort ending in a definitive Phase III trial that involved more than 70,000 children in 11 countries that took four years to do, and probably cost $350 million. That whole program, which cost more than $1 billion, was done in collaboration with Merck. I got to watch firsthand for a quarter of a century how hard it was to make a vaccine, to make sure that when you claim it was safe and effective, that it was safe and effective. Then you have in the late 1990s this paper that was published in The Lancet claiming that the measles, mumps, rubella vaccine caused autism when there wasn’t a shred of evidence to support the conclusion, and eventually the paper was retracted. But still, what you can’t retract is the notion that vaccines might cause autism, so it scared people. I watched on the one hand how hard it was to make vaccines, and how easy it was to damn them, so we created the Center as a way to try to educate parents and the public and the media about vaccine safety. We wanted to get the scientists’ viewpoint out there instead of just Jenny McCarthy’s.
Q: How do you work to counter all of the negative and false information that’s out there?
A: We write books, we write articles, we write op-ed pieces, we create educational videos, we have tear sheets, we have movies, we do radio, television, and newspaper interviews, we do anything we can to try and get good information out there. It’s hard. It’s harder than making a vaccine. What we’re trying to do is influence how people think about vaccines by giving them good information, which is hard because you’re competing against a lot of awful information that’s on the internet.
Q: Has there always been some sort of level of controversy around vaccines?
A: Always. The first vaccine [for smallpox] was in 1796 and by the early 1800s there was something called the Anti-Vaccination League in protest of that vaccine. I think the birth of the modern American anti-vaccine movement was in the early 1980s with the false concern that the whooping cough vaccine causes permanent brain damage. It had to do with a ‘Dateline NBC’ piece called ‘DPT: Vaccine Roulette’ claiming, falsely, that the vaccine caused permanent brain damage. I talk about that at some length in my book ‘Deadly Choices.’
Q: Do you think misinformation is the main cause of concern that some people may have about vaccines?
A: I think the problem is that people don’t fear the disease. You didn’t have to convince my parents to vaccinate their children because they saw diphtheria as a killer of teenagers and because they saw polio. You didn’t have to convince me to vaccinate my children because I had many of these diseases. I was a child of the ‘50s, so I had measles, I had mumps, I had German measles or rubella, I had chicken pox. I had all those diseases so I know what it felt like. My children not only don’t see these diseases today, they didn’t grow up with these diseases, so for them, this is all a matter of faith. You’re asking people to have faith that it’s important to still do this. Faith in whom? Faith in the pharmaceutical companies, faith in the medical establishment, faith in the government. I think there has been an erosion in that kind of faith. I think we are compelled by fear more than reason, and we don’t fear these diseases. I would argue that vaccines are a victim of their own success, but on the other hand, I would argue that the anti-vaccine movement is also starting to become a victim of its own success because it’s now convincing enough people not to get vaccinated that some of these diseases are coming back. And for the first time in my memory, other parents are now angry at parents who have chosen not to vaccinate their children. They’re angry that those parents have made a choice not only to put their children at risk, but those with whom [their children] come in contact at risk. This Disneyland outbreak has been a turning point. There are at least seven states that are now considering overturning philosophical exemptions to vaccination because of this outbreak because there’s a societal contract.
Q: You talked about the importance of herd immunity. How does herd immunity work?
A: If you vaccinate enough people in a population, then it becomes more and more difficult for a virus or bacteria to spread in that population because there are not enough susceptible hosts. You need [herd immunity] because there are hundreds of thousands of people in the United States who can’t be vaccinated because they’re getting chemotherapy for their cancers, or immune-suppressive therapy for their chronic diseases, or because they’re too young. They depend on the herd to protect them; they depend on living in the herd. Do we have a responsibility to them? I think we do.
Q: So without herd immunity, it’s possible that there could be an outbreak of any one of these diseases?
A: You’re seeing it a little. You’re seeing it with whooping cough; you’re seeing it with mumps. You’re seeing it with measles. There’s still varicella or chicken pox in this country. There’s really not a year that goes by at Children’s Hospital of Philadelphia where we don’t see a child suffer or die from diseases like influenza or whooping cough or pneumococcus. Invariably, it’s because parents made the choice to leave that child vulnerable because they weren’t scared of the disease. If you listen to these parent advocacy groups—groups like Families Fighting Flu, or Meningitis Angels, or the National Meningitis Association—those parents all tell the same story: ‘I can’t believe this happened to me. I can’t believe it.’ Then they become vigorous activists for educating the public about the disease and about the importance of the vaccine, but it had to come to that. They had to watch their own child suffer or be permanently harmed or die before they got it. It shouldn’t have to come to that. Why do we have to have a measles outbreak in order to educate people that a measles vaccine is important? Why do children have to suffer? Because the children are always the first to suffer our ignorance, frankly.
Q: What would it take to eradicate one of these diseases?
A: Some diseases are easier to eradicate than others. Smallpox has been eradicated. Frankly, type 2 and 3 polio have been eradicated, so we really are just down to poliovirus type 1. I think we’re on the verge of eradicating polio. You could eradiate diseases like measles and mumps and German measles and chicken pox if everybody who can be vaccinated would be vaccinated. Those are eradicable diseases. It’s hard to eradicate diseases like influenza, whooping cough, and rotavirus. Those are harder.
Q: Rotavirus kills nearly 600,000 people a year, primarily in the developing world. How is your RotaTeq vaccine doing?
A: There are two vaccines. One was invented by researchers here at Children’s Hospital of Philadelphia and the other was invented by researchers at the Children’s Hospital of Cincinnati, so there are two rotavirus vaccines that are getting out there in Asia, Africa, Latin America, and they’re saving lives. I think you could argue that those vaccines save hundreds of lives a day.
Q: How has the vaccine been received? Has it faced a lot of criticism?
A: First of all, the vaccine is given by mouth. I think the public perceives a vaccine that is given by mouth differently than they perceive a shot, so our rotavirus vaccine generally hasn’t come under the same criticism that some of these other vaccines have.
Q: Do you think the anti-vaccine movement is gaining momentum? Their theories seem to be getting more press and some political support.
A: I’m not sure it’s a movement as much as a sentiment. I think that people don’t fear the disease so you’re seeing pushback, and it’s not surprising. You ask citizens in the United States to give their young children vaccines that prevent 14 different diseases. That can mean as many as 26 inoculations in the first few years of life to prevent diseases that most people don’t see using biological fluids most people don’t understand, and you can get as many as five shots at one time. I don’t think it’s surprising that there’s pushback. But as you push back, as you choose to leave your child vulnerable, then you start to see these diseases come back. Now it’s shifted back again where people are now angry. Supposedly, more of these parents are getting [their children] vaccinated against measles in Southern California than ever before because of this [Disneyland] outbreak, so they’ve responded to the fear. This is something that my parents certainly knew about and I certainly knew about that my children don’t know about. Now they know. I guess [people] had to see the disease before they believe it; I guess seeing is believing. They chose not to learn from history. I think it’s going to be cycles. You’re seeing a cycle now where people are getting vaccinated again because they’re scared of these diseases. Then the measles epidemic will die down and maybe we’ll get to the point again where we eliminate measles from this country and people will become complacent again, and then the disease will come back.
Q: Are there any side effects to taking vaccines?
A: Sure. They hurt. They can cause pain and redness at the site of injection. Sometimes they cause you to faint. Some vaccines contain stabilizers or manufacturing residuals that can cause an allergic reaction. The measles-containing vaccine can cause a lowering of the platelet count, but that’s very rare. For the most part, vaccines are remarkably safe. I would argue they’re the safest, best-tested thing we put into our bodies, certainly safer than megavitamins, certainly safer than antibiotics. They would have to be that safe because we’re giving them to healthy children.
Q: The National Hockey League had a minor mumps outbreak last year. How does something like that happen?
A: Mumps immunity can fade 10 years after dose-1; it can even fade 10 years after dose-2. These are young adults that were probably at least 10 years from their last vaccine. And they have close contact with other players, obviously, it’s the nature of the game, it’s a contact sport.
Q: Does CHOP see any of these diseases?
A: We see whooping cough. We see pneumococcus. Occasionally, we see chicken pox. We see flu.
Q: How do you treat people who have not been vaccinated when they catch one of these diseases?
A: Supportively. If it’s pneumococcus, you have antibiotics, but for viruses like influenza, or rotavirus, or chicken pox, or measles, you treat it symptomatically.
Q: Your most recent book, ‘Bad Faith: When Religious Belief Undermines Modern Medicine,’ addresses people who disregard modern medicine in favor of using their faith to fight life-threatening illnesses. Was there a specific case or incident that motivated you to write the book?
A: Yes, the 1991 Philadelphia measles epidemic. We had an epidemic where, in a few months’ period in 1991, we had 1,400 cases of measles in this city, and nine children died. Five died within a 10-day period. It was one of the worst epidemics in this country’s history, and it was in a time when we had vaccines. We were 30 years into the development of a measles vaccine, yet still we saw all those cases. The reason is it centered on two fundamentalist churches in the city—Faith Tabernacle and First Century Gospel—both of which chose not only not to give their children vaccines, but chose to not give them medical care, so they prayed instead of giving oxygen for pneumonia, or prayed instead of giving intravenous fluids for dehydration, and their children died. For me, the motivation for writing this book was, one, to understand how parents can do that because these parents loved their children. It’s not like a typical case of medical neglect of a child where parents often are distant from their child. They loved their children; that’s why they prayed so hard for them. I needed to understand the psyche that allowed that, and two, I needed to understand the law that allowed it. We basically allowed that to happen. We still allow it to happen because we have in the state of Pennsylvania a religious exemption to child abuse and neglect laws, which I would argue is a contradiction in terms. A religious exemption to child abuse and neglect? If it’s child abuse and neglect, how can it be religious?
Q: Are there any diseases that you think there could potentially be a vaccine for within the next 25 years?
A: Sure. Malaria. Dengue. Norovirus. A virus called respiratory syncytial virus, or RSV. Human immunodeficiency virus, HIV. I think we could have a better tuberculosis vaccine.