Is Popeye More Likely to Respond to Vaccination?

(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.

Background

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.[1]

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. [2]

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?[3] 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).[4]

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.

Big Picture

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.[5] 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.[6]

This is interesting for two reasons:

  1. 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.
  2. 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.

Bottom line

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.

It’s because we are unwise enough to have 60% vaccine coverage, in a disease that needs at least 80% to prevent epidemic spread.

Learn more

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.

Third world skepticism


[1] 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.

[2] 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.

[3] 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.

[4] 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.

[5] 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.

[6] 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.

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A delicensed heart surgeon misleads you about what causes heart disease

There is another strange medical thing making the Internet rounds again.

People are asking me what I think, so I will tell them, and anyone else who cares.

These are useful things to review not because they are particularly sophisticated bits of media (they aren’t) but because we can learn things about how to assess such material for ourselves.

The first is called “Heart surgeon speaks out on what really causes heart disease.” I’m going to address this according to the various rhetorical tricks or tactics that the article uses, which is authored by a Dr. Luddell.

Right off the top, consider the source. The same webpage tells us that “Strong evidence links vaccines to autism.” As readers of this on-line rag have learned before, this is fear-mongering nonsense. Such evidence simply does not exist. Anyone who claims it does is either misinformed, lying, or incapable of assessing scientific evidence.

But, leaving that aside, let’s consider the arguments and tactics.

Continue reading

Vaccines and breastfeeding

I occasionally meet parents who have decided to delay vaccinating their newborn.

Such parents have usually been alarmed by false claims about the risks of vaccines to children, which I have discussed earlier.

Another common worry is that children are “too small” for such vaccines. This simply isn’t true. Vaccines are timed for when a child’s immune systems will respond to them. This is why, for example, polio vaccines are given beginning at age 2 months, while measles waits for 1 year of age—a two-month-old won’t respond properly to a measles vaccine, but will to polio. (Getting such vaccines too soon wouldn’t be dangerous, but it wouldn’t generate an immune response, so there’s no point.)

Parents of unvaccinated children sometimes comfort themselves with the thought that since they are breastfeeding, this provides adequate protection. After all, there are antibodies against disease in breast milk, right?

Breastfeeding is certainly the ideal choice for the vast majority of newborns and their parents. (There are a few diseases or conditions for which you shouldn’t breast feed, and a few drugs that a mother might have to take that would be dangerous to an infant.)

It is also true that antibodies from the mother are passed in breast milk to the baby. But, parents often don’t know what kind of antibodies, and what kind of protection they provide.

And, that’s the rub, as they say.

The Children’s Hospital of Philadelphia has a Vaccine Education Center. Their statement is important:

Sometimes parents wonder whether they can forego immunizations for their baby because the baby is being breastfed; however, this is not the safest decision because antibodies in human breast milk bathe the intestinal surface but are not absorbed. Therefore, breast milk antibodies never enter the lymphatics or circulation where they would be needed to protect against diseases for which infection in the blood (circulation) is an important part of how viruses and bacteria cause disease. Examples of these types of diseases include diphtheria, tetanus, pertussis, measles, mumps, rubella, varicella (chickenpox), pneumococcus, Haemophilus influenzae type b, polio, hepatitis A and hepatitis B.

Antibodies in breast milk enter the baby’s gut. These antibodies are useful, but their only function is to prevent the baby’s gut from absorbing dangerous infections. So, breast milk antibodies are a great way to help prevent things like diarrheal illnesses. That’s no small thing—in the third world, diarrheal illness still kill millions of children every year. (Even in the US, hundreds still die every year from diarrhea.)

So, before modern sanitation and germ theory, breast milk antibodies could mean the difference between a child living and dying, and still does in the third world. (This is one reason why efforts of baby formula companies to convince third world mothers not to breast feed are so pernicious.)

But, breast milk antibodies do not enter the baby’s blood stream or lymphatic system. They stay in the gut. So, breast milk antibodies are completely powerless to fight any infection that enters a baby by any other route—for example: by the lungs, by a scratch on the skin, and so forth.

So, antibodies in breast milk might protect your baby from stomach flu—but, they won’t protect him or her from some of the worst diseases known, including:

  • tetanus (lock jaw)
  • polio
  • hepatitis A and B
  • pertussis (whooping cough)
  • measles
  • mumps
  • rubella (German measles)
  • diphtheria
  • pneumococcus (causes severe pneumonia).
  • H. influenza, type b (causes potential fatal airway compromise)

It is a sad irony that parents worry that their baby’s immune system “can’t handle” vaccinations. It can, easily.

But, their immune systems can’t handle all the above diseases very well at all—newborns are at greatest risk of death or life-long problems from these diseases in the event of an outbreak. This is because of a less well-developed immune system, and the fact that they are smaller.

A baby’s best lines of defense are:

  1. vaccination for themselves; and
  2. herd immunity from a well-vaccinated population for those diseases for which they are too young to mount a proper response.

Once again, your choices don’t just affect you—they affect my kids too. We all need that herd immunity.

Here’s hoping people will use science, and not fear, in making these decisions.

Vaccines and autism – an update

Vaccines and autism: the history and an update[1]

Note: Readers might also want to check out my later post on the “autism epidemic“.

In 1998, a doctor in England named Andrew Wakefield[2] (in conjunction with other physicians) published a paper which suggested a link between the MMR (measles-mumps-rubella) vaccine and the development of autism.[3]

Understandably, this raised an enormous amount of concern. Vaccine rates dropped. Parents today remain worried about this.[4]

As it turned out, Wakefield had falsified patient information, distorted data, and did not disclose that he was being paid by lawyers that wished to sue vaccine companies. Eventually, the medical journal took the almost unprecedented step of retracting the paper, and all his other co-authors disclaimed the study. Wakefield lost his medical license for his role in the fraud.[5]

The damage, however, was done. Parents continue to worry that “vaccines cause autism,” or some variant. Even though the only evidence of this was faked and cherry-picked data, people continue to worry.

It is understandable that parents whose children face a difficult illness (I have two nephews with the condition, so I understand the difficulty and some of the worry and pain) would seek for a reason. And, since parents and medical personnel often begin to notice the behavioral difficulties that accompany autism around 12-18 months (the time of the MMR vaccine), it is easy to see how parents might see a link where there truly isn’t one.

But, no one is well-served if we adopt false ideas about the cause of autism, especially when parents opt not to vaccine for deadly diseases—they put themselves and my children at risk.

No vaccine is 100% effective, but if enough people are vaccinated, the rest are protected by what we call ‘herd immunity.’ Babies too young to be vaccinated are likewise protected. So, a decision of someone to not vaccinate does not just affect their child, it affects my child and your child.

We know very well  what happens when vaccine rates drop—the diseases against which they protect us come roaring back. (This happened in the UK and Japan with the MMR scare, and in the former USSR when their vaccine practices lapsed with the fall of Communism. One can’t say much for Communism, but it was at least good at getting everyone lined up for their diphtheria vaccination.)

The Evidence

Three major theories have been offered by those who claim that vaccines are a cause of autism. (A big proponent of these has been former Playboy model Jenny McCarthy on the Oprah Winfrey show—though what qualifications Ms. McCarthy has to make declarations about such matters is not clear. I somehow don’t think that Hugh Hefner is running microbiological seminars at the Playboy Mansion.)

#1) MMR link — as noted, this was due to Wakefield’s fraud. Since then, twelve studies have been done looking for a link, and none has been found. It is impossible to prove a negative in science, but this is pretty good evidence.

#2) Thimerosol — the second claim is that a preservative put in some vaccines (thimerosol) caused the problems. Thimerosol contains mercury, and so it was easy for those who didn’t know much biochemistry or who wanted to spread fear to claim it was a poison or toxin. (In fact, we now know that this form of mercury is much less toxic than others; it was removed from vaccines anyway as a precautionary measure, though there is no evidence that it causes any known human problems at those doses.)[6]

But, even though the claim doesn’t make much theoretical sense, seven studies have failed to find an association between thimerosol exposure and autism. Furthermore, thimerosol is not used in the vast majority of childhood vaccines anymore (the annual flu vax still uses it), and yet autism rates have not altered downward at all—they’ve continued to climb. So, this theory hasn’t panned out either.

#3) Too many vaccines?

This has been the hardest claim to answer. The worry is/was that because more vaccines are now given to children, this has somehow “overwhelmed” their immune system.

On its face, the claim makes very little sense. Children are exposed to thousands of different types of viruses, bacteria, and other stimulants of the immune system every day. Exposure to just one bacteria will trigger our body to form between two and six thousand different antibodies.

The food we eat, the water we drink, the air we breathe, the dust we work around, the animals we have as pets—all of these will expose us to thousands upon thousands of items that will cause us to form millions upon millions of different antibodies.

So, it is hard to see how a few extra vaccines could cause a huge disaster. (There’s even evidence that being so “clean” these days has increased our risk for asthma and other auto-immune disorders—we probably don’t get exposed to enough bacteria and dirt. But, that’s a topic for another time.)

A past study showed that the number of vaccines given in the first year of life had no impact on whether a child developed autism.[7]

Now, a new study has just been released, demonstrating that the number of antigens stimulated does not influence the development of autism.[8]

Simply put, if you are given more vaccines that stimulate more antibodies, this doesn’t affect your risk of autism either. So, that’s a further nail in the coffin for theory #3 (which doesn’t make much sense even on the face of it, since the number of antigens we’re adding with vaccines is miniscule compared to the total that a child is exposed to in the course of daily life).

And, it’s one more nail in a theory that has never had any real scientific support at all—except “support” manufactured by Andrew Wakefield.

A single lie can do a lot of damage.

And, Andrew Wakefield told a lot of lies.

Postscript

And, interestingly, there’s another nail in the “too many vaccines” argument too.

It is true that children today receive more “shots” than children in (say) the 1990s (or the 1950s).

But, what is interesting is that although the number of shots has risen, the number of antigens has dropped.

Why?

Here’s a simple example. We used to vaccinate against pertussis with a whole-cell, killed bacteria. That single bacteria caused the body to make around 3,000 antibodies—because the bacteria was coated with about 3,000 proteins or glycoproteins, all of which the body recognized as a bad, foreign invader.

Now, we have an “acellular” pertussis vaccine. This uses just a bit of the protein coat to create immunity, not the whole bug. Guess how many antibodies it stimulates? Six or less.

Bottom line, a child following the US guidelines in 2013 is exposed to only 315 antigens over the first two years of life from vaccines. In the 1990s, that number was in the several thousands.[9]

And, it’s really hard to see how 315 extra antigens—a drop in the bucket of what your immune system deals with each and every day, if not each and every hour—could do any harm. And, when you look at dozens of studies, that’s what it shows about autism.

Especially when they protect us from some of the most terrible diseases known to man.

So, do your kids and my kids a favor—ignore the fearmongers, and get your shots.


[1] Based on an article here: http://www.medscape.com/viewarticle/782298. I’ve expanded and added further explanation.

[2] See http://en.wikipedia.org/wiki/Andrew_Wakefield. I got some references from this article.

[3] Wakefield AJ, Murch SH, Anthony A et al. (28 February 1998). “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children”. Lancet 351 (9103): 637–41.

[4] See TIME magazine’s article on “Great Science Frauds,” TIME Magaine, 13 January 2012.

[5] Meikle, James; Boseley, Sarah (24 May 2010). “MMR row doctor Andrew Wakefield struck off register”. The Guardian (London). Archived from the original on 27 May 2010

[6] “Thimerosal in vaccines: frequently asked questions (FAQs)”. Center for Biologics Evaluation and Research, FDA.