(or, Why blaming nutrition is not your anti-vax get-out-of-jail-free card)
In Southern Alberta, we are currently in the midst of a measles outbreak.
Some have asked me recently about the claim that better nutrition would lead to better vaccine response.
The purpose of this claim seems to be an attempt to disprove concerns about herd immunity.
No vaccine is 100% effective. Those who do not respond to the vaccine, and patients that are too young to be vaccinated, depend upon herd immunity for protection—measles (or other infectious diseases) can’t get established in a population unless there is a certain percentage of vulnerable people.
So, when those who through bad science or their own philosophy reject vaccination, they increase the risks to everyone. If you don’t want to get a tetanus vaccine, fine—the only person you’ll kill or cripple is yourself.
One dose of measles vaccine is typically 95% effective. A second booster can get that to 98-99%. But, it ain’t 100%. Bluntly, if you forgo things like measles vaccines, you put me and my kids at risk. You also put kids with leukemia, and patients with HIV, and newborns too young to be vaccinated, and a variety of others at risk too.
(89% of patients in the USA in 2011 who got measles had not been vaccinated. But, 11% who got it had been. Thanks a lot.)
Blame the victims
Now, this seems like a pretty crumby thing to do—and it is. So, some are now claiming that they aren’t really putting your kids at risk, because vaccines work better if you have better nutrition. The subtext is clear—if you get the measles vaccine and you don’t respond to it, it’s your own darn fault for eating such a lousy diet, or not taking some vitamin supplement, or whatever. (If they go a step further and try to sell you the supplement, run away.)
We are supposed, then, to blame the lousy diet of people who do get vaccinated, and not the irrational and scientifically unsupportable decision of the vast majority of those who choose not to vaccinate.
This might be a compelling argument—if it were true. But it isn’t.
The First World and the Third World
It’s always a bit dubious when people start bemoaning poor nutritional status in North America. If anything, we eat too many calories and the like; we do not typically have a problem with macro- or micro-nutrient status (with some subgroups being exceptions, which I shan’t go into here).
But, for the sake of argument, let’s follow the claim, and see where it leads.
If poor nutrition was a significant factor in vaccine non-responders, that would be an important thing to know. Why? Well, for starters, when we give vaccines in the Third World, those people are at much higher risk of malnutrition, poor vitamin status, and all the rest than anyone in the First World would ever be in their worst nightmares. So, if nutrition is a factor in measles vaccine response, we ought to be able to detect that in the Third World especially. We’d like to know, because maybe it would be better to give them some vitamins or better nutrition, and then vaccinate them later. (A similar analysis could be and has been conducted for a variety of vaccines; I will focus on measles because it is the one in the news right now.)
If you go way back to 1980, this question was looked at for smallpox and measles. The conclusion:
Malnutrition did not affect the children’s ability to develop adequate immune response to measles o[r] smallpox vaccine, and there were no major complications during the 8-week period of follow-up. Since measles is a very severe disease, which in malnourished children can carry a case fatality rate as high as 50%, malnutrition should be a prime indication for measles immunization, and certainly not a contraindication.
No effect—and many of these kids were severely malnourished.
Is 1980 too long ago? Well, here’s one from August of 2013.
It looks at kids who are both malnourished and have potentially disastrous risk factor: kids with HIV+ mothers. This is a randomized, placebo-controlled trial that gave some kids vitamin supplementation prior to measles vaccination.
The stage of the mother’s HIV affected how well the kids’ immune system responded—more advanced HIV made it more likely for the children to respond. But, what about the “nutrition” that we’re assured is so important?
There were no effects of infant multivitamin supplementation on measles seroconversion proportions, IgG concentrations, or IgG avidity. 
Translation: Seroconversion means developing protective antibodies; IgG concentration is how much antibody; IgG avidity is how well the antibody binds to measles.
Long story short—giving the kids vitamins made no difference at all to the vaccine responses, and they’re from Tanzania.
Are we really expected to believe that a kid in North America—no matter how lousy his or her diet—is in worse nutritional shape than a child born to an HIV+ mother in Tanzania? Well, anti-vaccination activists have asked us to accept bigger whoppers than that, so I guess we shouldn’t be surprised.
An ironic risk—would supplements be risky?
Ironically, the public health worry about malnutrition and supplementation has been whether supplementation might worsen the measles vaccine response rate. It would be great to give all the kids you saw in your third world vaccination clinic Vitamin A—this has been shown to be cost effective, and they need it. It’s hard to get them into the clinics; they have to travel a long ways sometimes, and wait a long time. How great would it be to do both at once, if you can? But, what if doing one makes the other less effective? This actually might have happened when some six month old kids were vaccinated. (They were vaccinated early—but, this is a scary prospect, if true.)
Well, this has been looked at—happily, there is no concern so far.
Overall, the seroconversion rates did not differ between vitamin A (89.5%) and placebo (87.6%) groups. There were no significant differences in the geometric mean titers in the two groups (ratio of geometric means, 1.19; 95% confidence interval, 0.97–1.46). Among malnourished infants, the geometric mean titer was significantly greater in the vitamin A group compared to the placebo group (ratio of geometric means, 1.57; 95% confidence interval, 1.18–2.0), but seroconversion rates did not differ. There were no differences in seroconversion rates and geometric mean titers in the two study groups among the well-nourished children. These results indicate that 30 mg vitamin A does not reduce the immune response to the coadministered vaccine and, therefore, can be continued to be given safely in public health programs (emphasis added).
Note that antibody levels were slightly lower in malnourished kids—but, there was no statistical difference between malnourished or well-nourished children in whether they’d have measles immunity or not.
But, it’s ironic that the thing that worried real vaccine scientists is the exact opposite of what the North American anti-vax nutrition pushers claim—the worry was that supplementation in people who were truly malnourished might actually decrease the vaccine’s effectiveness. It certainly didn’t increase it.
Am I, perhaps, merely cherry-picking studies? Am I just finding a few that support my position, while ignoring the others?
A fair question. Fortunately, someone recently did an extensive analysis of all vaccines and all the data on nutrition status and response to those vaccines. (This was done for the Bill and Melinda Gates Foundation, which was founded by the Microsoft billionaire and his wife. They do really good work, and it is intensely data-driven.)
This review was published in 2009, and full text is available. Here’s some measles-related highlights (emphasis added in all cases):
- “Our analysis indicates that malnutrition has surprisingly little or no effect on vaccine responses.”
- Protein-energy malnutrition “studies did not show any association between malnutrition and the immune response to M[easles] Vaccine.”
- A few studies did show that children with kwashiorkor (severe, starvation-level protein lack in the diet—there are very disturbing pictures here if you want to see how bad we’re talking) had lower responses to measles vaccine. But, some of these studies only waited two weeks to see if there was a response—in other studies of kwashiorkor, malnourished children delayed their response to the vaccine, but by three weeks had, like the well-nourished, a good response.
- Young children (6 months) given Vitamin A [VA or Vitamin A supplementation=VAS] have lower response rates, but only if they have high levels of antibodies from their mothers. “Moreover, a clinical trial in Bangladesh assessed the effect of VA supplements on M[easles] V[accine] response when administered near to vaccination or not. VAS administered within 4 wk before or 2 wk after measles vaccination was not associated with altered vaccine failure rate compared with administration of VA outside these time limits.” In sum, “although mean antibody titers tended to be higher in participants who received VA, seronconversion rates were universally high and did not significantly differ between supplemented and unsupplemented participants.”
- Data on iron deficiency is poor, but “children with iron deficiency anemia seem to have intact antibody responses to vaccination. Although iron deficiency is known to affect T lymphocytes, the antibody response is preserved, even when it requires help from T h[elper] cells.” Likewise for Vitamin D, “there is no evidence that vitamin D has any effect on vaccine response,” though the data is very sparse.
- Zinc supplementation may affect cholera vaccine response, but not “BCG, diphtheria and tetanus toxoids, rabies, influenza, and pneumococcal vaccines.” Measles has not been looked at at all.
- “We found occasional evidence of marginal effects of micronutrients, but the evidence base is very limited and frequently contradictory.” It is hard to see how these type of effects, which can barely be discerned (if they exist at all) in Third World populations could make much of a difference in North America.
Summing up the data
The authors frequently return to the fact that there isn’t a ton of data on this topic—which should tell us that if they don’t know, then the confident assertions of those in North America who claim that “studies show” that nutrition is a big factor in First World vaccine failures are talking out of their hat. Thus, far, we can barely find any evidence in the Third World in horrendous circumstances:
Surprisingly, we found little convincing evidence to indicate that current nutritional status or coadministration of nutrient supplements has clinically important effects on vaccine efficacy.
To claim that the non-responders have only their poor diet to blame if they get measles—instead of what is essentially a superstitious or pseudoscientific decision of non-vaccinators to forgo vaccination—just isn’t supported by the facts.
So, why do some people not respond to vaccines?
This is an active area of research. There’s a very interesting bit of data out of Israel that compared desert Bedouin Arab responses to measles vaccine versus Israeli Jewish children.
This is interesting for two reasons:
- From a nutrition standpoints, the Bedouins are at a disadvantage—they have much larger families (9 children on average), live in crowded, relatively unsanitary conditions, have many more infections, and almost certainly have a lower standard of living and access to much less robust food supplies.
- Genetically, the two populations are different.
Intriguingly, the Bedouin had a 99% conversion rate, while the Jewish group had only a 79% response—astonishingly low. This was not a one-time fluke either—a previous study of Jewish children had likewise 24% not respond to the vaccine, despite having evidence they were vaccinated.
This sort of thing isn’t confined to the Middle East. Studies have observed:
- First Nations people responding better than Caucasian Canadians;
- East Indians responding better than Africans;
- Twin studies show that identical twins have a higher rate of vaccine failure if one twin fails.
You see where this is headed—vaccine response depends, at least in part, upon genetic factors. The mechanisms for this are just beginning to be explored, but they have to do with mutations to the receptors. Some mutations improve your response, and others decrease it.
So, a large part of whether you respond is simply a genetic luck of the draw. We can’t eat our way out of it.
So, if you’re not going to vaccinate yourself or your kids, please—at least be honest about the facts. You’re putting them at risk. But, you’re also putting the rest of us at risk too.
It isn’t because we wouldn’t eat our spinach.
For information about measles , go here.
If you think you or someone may have measles, do not go to the ER. Do not go to the doctor’s clinic. Do not go out in public.
If you live in Alberta, call this number, and do what they tell you: 1-866-408-5465.
 AE Ifekwunigwe, N Grasset, R Glass, S Foster, “Immune responses to measles and smallpox vaccinations in malnourished children,” Am J Clin Nutr 33/3 (March 1980) :621–4.
 Christopher R. Sudfeld, “Effect of Multivitamin Supplementation on Measles Vaccine Response among HIV-Exposed Uninfected Tanzanian Infants,” Clin Vaccine Immunol 20/8 (August 2013): 1123-1132.
 Recall that having HIV+ mother doesn’t just expose the child to risk of infection—such women are less likely to be well, are less able to work, will probably make less money in a country not known for high-riding lifestyles, and are less able to provide food for the baby, etc. You’re at risk in this situation.
 Rajiv Bahl et al., “Vitamin A Administered with Measles Vaccine to Nine-Month-Old Infants Does Not Reduce Vaccine Immunogenicity,” The Journal of Nutrition 129/8 (August 1999): 1569–1573.
 Mathilde Savy et al., “Landscape Analysis of Interactions between Nutrition and Vaccine Responses in Children,” The Journal of Nutrition 139/11 (November 2009): 21545–22185.
 Bracha Rager-Zisman, et al.¸ “Differential Immune Responses to Primary Measles-Mumps-Rubella Vaccination in Israeli Children,” Clin Diagn Lab Immunol 11/5 (September 2004): 913–918.