Wednesday, March 5, 2014

Thinking ahead (on vaccination strategies)

Today marks 32 weeks. Rather unbelievable. I've started buying stuff, which freaks me out quite a bit. I have to make a significant purchase/decision soon: the mattress. The options for cribs in India don't seem so bad. The options for mattresses suck. They are all made of PVC foam or are "antibacterial,"which is just a fancy sales gimmick, but is actually far from ideal. And pillows. OMG, does the Indian baby market abound in these. I shudder to think who would buy, for example, this product. Despite the rather appalling lack of consumer awareness, surprisingly, the incidence of crib death is lower in India than that in many other countries.

So I'm going to have to buy my mattress from the US, or get it made myself (you can get gaddi makers to do it, and could could source cotton materials yourself). For multiple reasons, I would rather go with option #1; right now, I'm thinking Naturepedic. If anybody has any thoughts/ideas on this subject (also on making your own mattress; I'd love to, but I have little know-how), I would love to hear them.

A few days ago, I told a really close friend of mine, who had a baby 6 months ago, that I was going to be having a baby soon. She was my roommate when I first started trying over 3 years ago, and was incredibly supportive then. Her reaction when I told her now blew me away: she offered to express and freeze breast milk for me! I'm not going to turn this incredible gift down. If I get even a few days worth of partial feeds, it would make me feel so much better. She is such an amazing friend.

Finally, we come down to a controversial topic: Vaccination. As an immunologist, I was initially appalled at how early vaccinations start in the US. Then I compared the Indian schedule to the American schedule, and I realized that the American one is actually a tad better in comparison. In the US, only the HepB vaccine is given at birth; here 3 vaccines: HepB, BCG, and the Polio vaccine is given at birth. All three are for diseases a newborn is unlikely to catch in today's day and age, especially if you come from a situation where the baby will be kept mostly isolated after birth, which would cut down the TB risk. I am sure these were designed keeping the poorer section of the populace in mind, but none of these is anything my baby is at risk for.

Indian rules aside, overall, vaccine policy in the world is rather flawed, although everybody who attacks vaccines seems to be making the wrong argument. I spent a good part of my career studying the cells that the vaccines are directed towards, so every time somebody told me about a a bunch of vaccines that would be given when the baby was 6 weeks old,  I would get a headache, because the immune system of young infants is not yet ready to optimally respond to a vaccine, because it is still developing. If you give a 6-8-week old baby a bunch of vaccines, it will not result in optimal protection; very far from it actually, it could mildly hamper the immune response towards the targets. Additionally, if the immune response is not optimal (which is very likely if 6 vaccines are given together at 2 months of age), your child may be protected for the next few months, but despite boosting, may not efficiently develop long lived protective immunity in the form of memory B cells, which is supposed to be the goal of a vaccine. All this is covered very well in this Nature Reviews Immunology article; I would urge the doctors (especially any pediatricians) visiting this page to read this.

 Moving away from the efficacy of multiple vaccines given at two months of age, vaccines given at birth are even worse, and are most likely utterly useless, for multiple reasons. One important one is that they will most likely be neutralized by the antibodies that the mother passes to the baby in the last trimester. For example, most mothers have strong immunity against Hepatitis B, and their antibodies, which protect the baby for about 20-30 days, will most likely neutralize the vaccine that is given at birth. So why bloody bother giving the vaccine at this point?

Another downside is that the vaccines themselves are a terrible jolt to the system. There is  no concrete evidence to indicate that the vaccines cause autism or have any long term side effects, but still, to err on the side of caution and also to ensure that they work in the way they were intended to work, I would rather wait till my baby was older (atleast 3-4 months) before I started vaccinating, and then go for a very staggered schedule, with longer intervals (3 months maybe) between boostings.

Yet, I understand the dilemma faced by both parents and medical officials: what if you cannot isolate your baby, and you have to travel with them, or send them to daycare regularly from an early age? If you are a parent with a micropreemie, the situation would also have to be handled differently. 

But, when it comes to full-term/close-to-term babies who can stay home and relatively isolated for the first few months of life, there is a better way available to do things.  Yet, the truth that doctors will not tell you (possibly because they do not understand it themselves; the only ones who would would be the immunologists who have an in-depth understanding of B/T cell biology) is that that very early vaccinations produce crappy/inefficient immune responses, and the longer you wait to vaccinate, and give fewer vaccines at one time, the better the immune response and the efficiency of the vaccination. Keeping the last point in mind, there is one alternative vaccination protocol from Dr. Robert Sears that has been doing the rounds; It is popular, as well as controversial. My opinion is that some aspects of this protocol (giving only two vaccines at a time in the first year of life) may produce better results than the regular protocol. It would be interesting to study antibody titres in babies subjected to the two schedules. Maybe that would put an end to all the bickering and the uncertainty. However, I am not too enamored of the dragging out of the vaccinations in the Sears protocol after the first year of life; somebody mentioned that even the most well meaning of parents could just lose track of the vaccinations if they are being dragged out, and that seems like a fair point. After babies are no longer classified as "infants," their tolerance and their immune robustness is closer to that of an adult, and the kid gloves (ha ha) could come off partially at this point. This is especially so after 2 years of life, when they start responding well even to polysaccharide vaccines. But this is an incredibly complex area, and my simplified take does not even begin to touch on some of the other issues (for example, is it better to get chickenpox as a kid, or be vaccinated against it).

In my own case, if I can manage relative isolation (no daycare/travel for the baby, and as little contact with the outside world for the first few months of life as possible), then I'm going to delay the start of vaccinations for as long as I possibly can (maybe up to 4 months). Ideally, I would have loved to start vaccinations only after the baby crosses a year of age, but unfortunately, we cannot live in a bubble for that long. There are additionally multiple ways to ensure that your baby's fledgling immune system is as optimized as possible, but that is a topic for another post.

23 comments:

  1. Sorry I think the cdc knows more than you. Read the Pediatrics article that addresses all the staggered vac myths propagated by the Sears franchise.

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    1. Lol..I did read the pediatrics article, and it conveniently bypasses a lot of studies that show that the antibody titers and generation of long lasting immunity may indeed be impaired by the 6-vaccines-at-one-go at 6 weeks approach; it seems like a doctor (and not a scientist with a really technical grasp of things like the need for co stimulation, competition for germinal center responses, etc) wrote that.

      I am actually not a fan of Dr. Sears apprach, but I'm far less a fan of the official approach. My point is that early vaccination basically creates a shitty immune response, and this response can be improved easily, and there are also fewer side effects when you give fewer vaccines at one go. The only advantage I see with the Dr Sears schedule is that it starts the vaccinations later (for some of the vaccines), and splits them up, which may be helpful, because it reduces competition in the B-cell pool during the developing immune response. And these are the points also put forth by somebody at the WHO (from the Nature Reviews Immunology article I quoted)---all of this is technically past most people who read both sides of the argument, including yourself, from the looks of it.

      The most ideal vaccination schedule would be somewhere between the Dr. Sears schedule and the CDC schedule, but most people would not be able to design one for themselves; if they had to pick one to go with, I'd say that the Sears schedule would be a tad better than the CDC one, but it is not optimized. Nonetheless, the thing to recognize is that there is no 100% correct answer/route here.

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  2. I'm so glad to hear an immunologist seems to have similar concerns as I do about the Hep B vaccine at birth. I KNOW I carry immunity to Hep B and I'm happy to have my child vaccinated for it, but at birth seems far too early and unnecessary. I am in favor of vaccines and will have my baby vaccinated on schedule, so long as he/she appears in good health on the day the vaccine is to be given, except for that one at birth. If a baby is less than 24 hours old, how can you be certain that he/she is healthy enough to receive a vaccine? It makes no sense to me. I think the next scheduled vaccine in the US is 2 months, I'll wait till then to make a decision, but 2 or 3 months sounds acceptable to me. Still, I'll be interested in whatever else you have to say about optimizing the baby's immune system.

    Meanwhile, I am amazed by your friend's offer. That's awesome! Congrats on making it to 32 weeks and good luck with the rest!

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  3. 32 weeks- congrats! I can imagine how exciting yet nerve-wracking getting the nursery ready must be. In weeks, you will be holding your little one. That is so wonderful!!!

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  4. Congratulations on 32 weeks - wonderful! So you still haven't been able to figure out the gender? That policy sucks! Interesting what you said about immunizations not working effectively and not being relevant for many babies who are more isolated for the first few weeks. Oh, and yay for your friend offering expressed breast milk!!!

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    1. Thanks! Yeah, still no idea. It is driving me NUTS :)

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  5. Your vaccine rationale seems sound to me! My girls' pediatrician does not like to vaccinate at birth, and I wholeheartedly agree, so we started at 2 months and all was well, even considering they entered daycare at 4 months old. WONDERFUL news on the breastmilk donation- yay!

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  6. 32 weeks, that's fantastic! Each week brings you closer to meeting that little one!
    Very interesting stuff about the vaccines, I have also wondered what schedule is best for doing them and I would be very interested if you did a post on the ways to ensure your baby's immune system is optimized.
    Also, that was a very kind offer from your friend!

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  7. Thank you for this post. It is great to hear the voice of someone who really knows! My daughter is not vaccinated - yet - but she is still breast fed at age two. I know that vaccines do have a lot to offer, having seen the difference that they have made in the tiny villages in Morocco. Ie the children are actually alive. Have you read the studies done in australia which allowed parents to delay vaccines until age two?

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    1. To be clear, I am DEFINITELY not advocating waiting till the age of two to start vaccinating. I would just want to delay it starting it for a while, till 4 months of age, ideally. Forget about Morocco; pertussis (whooping cough) and meningitis could kill in California, and they have.

      The protection offered by breastfeeding is very limited in scope, especially for deadly respiratory illnesses, because I cannot imagine the antibodies in the milk (IgA) getting to the places they need to go (I.e, the lungs). And you need broadly neutralizing IgG antibodies for true protection; breast milk will not offer that; only prior infection or an effective vaccination can.

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  8. Yeah for 32 weeks! And what a precious gift from your friend! I forgot you hadn't been told the gender yet...I thought you were just keeping that info private. Oh the suspence!!

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  9. First of all, congratulations on your 32 week mark!! Sooner than it feels, you'll be a mommy. And an awesome one at that! Second of all, that friend of yours is beyond awesome and my feelings towards her are torn...She just upped the friendship bar really high, how are any of the rest of us, mortals, compete? :)). I am really happy you are getting such great help. It is indeed incredibly generous of her.
    On a last note: oh my goodness, THANK YOU for this post. I would actually share it on facebook for some "know it all" radically pro or anti vaccine people to read. But I know I can't do that :). I am so amazed that so many of our former grad school colleagues with immunology background are so short sighted. And at the same time, I am so angry at all the anti vaccine people for coming up with such stupid arguments, that make all the rest good, solid worries get lost.

    To comment a little on the HepB vaccine. I totally agree with you, it is completely useless at birth when the mother does not carry the antigen. In US at least it was introduced mandatory in the 80's because of increased drug abuse and "loose" life style. It was preventive of mothers who might give the baby HepB. It makes sense in this regard, it is just stupid to force a mother who knows she does not have HepB, whose baby will not be at risk of contacting (in US the risk of getting HepB from transfused blood or dental work is so minimal, it's not even considered anymore). So, until the kid becomes sexually active or is suspected of doing iv drugs, the risk is close to zero. Why give it?

    So yes, too early is definitely a worry. Another worry is too many vaccines at the same time. Less than a month ago I got to read an awesomely well written grant proposal on measles (central nervous system tropism) and lymphocytic choriomeningitis virus (periferal, not CNS tropism). When viruses were injected separately, good protective immunologic response was achieved. When both viruses were injected at the same time, a lower antibody titer was detected AND on top of this these mice had severe CNS problems due to increased lymphocytic choriomeningitis virus (LCMV) specific T cells. And remember, LCMV does not have CNS tropism. Of course, the conclusions were that when more immunological stresses were present, non specific immune response occurs, often in tissues distant from the original tissue of infection (sort of immunological metastasis, if I were to compare it to cancer). I thought this was one of the best grants I laid my eyes on, but it was not funded!

    To be continued...
    Your friend M

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  10. To continue my worries about vaccines, I do admit that we need to vaccinate the kids. I am however against introducing 8 antigens(at the same time) into a 2 month old baby. I think it's irresponsible and useless. Reported vaccine side effects are 1% of what you hear when you talk to mothers. At least 80% of vaccinated kids have high fever and a depressed CNS (as observed by prolonged sleeping, lower reactivity, less eating) 24 hours after the vaccines. Mothers are told this is normal, no worries. At the same time mothers are told to rush the baby to the doctor if s/he is less active, has fever and what not and no vaccine was given. How is that so blatantly in our face, but we can't see it?
    And this takes me to the other aspect a vaccination in US. All or nothing rule. You do have the option to choose the vaccines when you go to the doctor. However, you can enroll your child in a state school ONLY if s/he has ALL vaccines done, or if you file for a religious exemption. Once you give a dose of vaccine it means you changed your religious beliefs and you have to go back to full compliance with CDC schedule. I am actually vaccinating my kid "under the table". Every time I go back to my home country I ask one of my formed med school friends to give her a dose of a vaccine she needs to get. This way I can continue with my "religious" belief exemption and my kid is protected responsibly against diseases s/he is truly at risk.

    I admit not all parents have the scientific background to make a decision. How should we proceed? More research. And after that, more research. It's not possible that vaccine research to be funded the same amount (or less) as anti aging creams.

    To end on a good note: the human body is incredibly resilient. We all recover from amazing stress we put on our bodies. Vaccination will severely affect a number of kids; we don't know the numbers because the side effects are considered normal, without considering that following a 24 hr fever a 2month old can have long term immune defect (either too low or too high). Not vaccinating at all is again irresponsible and can lead to awful epidemics.
    BUT, these are all small numbers. We pray that our kids do not make the small numbers in either team. Most of us survive under the "all or nothing" law. So let's celebrate all babies, vaccinated or not vaccinates. And here, on your blog, I'll celebrate your long awaited precious baby!

    The end:)
    Your friend, M

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  11. Lol for a while I was wondering who Orangesun is :) that was really informative, and the all-or-nothing rule is a little puzzling, and yes, sounds very stupid, if it actually does back people into a corner. I was planning on a staggered schedule (no more than two at a time). Now I'm wondering if I can do one at a time; would be a pain to keep track of, but the great thing about the Indian system is I can get the prescriptions and have my mom give like one shot every 15-20 days in the comfort of my own home. Poor kid would be a human pincushion.

    I'm not sure what sort of research is being done now. One easy thing to look at would be looking at antibody titers in children who get the broken up schedule versus the 6 vaccines at one go deal. God knows, there should be sufficient numbers of children in both groups.

    I can't beleive people are not considering issues like anergy, the lack of costimulation, and competition in the B cell pool.

    And it seems like vaccine strategies are going backwards, not forwards. I got the polio shot at 4 moths of age over 30 years ago. Now, the Indian association of pediatrics seems to be advocating it at birth, which is mindbogglingly stupid.

    Talk more soon :)

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  12. Oh wow - that is SO awesome of your friend to provide some milk for you! I was able to donate maybe 30oz to a twin Mom who had fallen behind and it made me feel great and helped her out. So thankful you were able to find someone who could help you out in India!

    We also skipped HepB at birth since I don't have it and I'm not worried about my newborn contracting it! For the most part we've followed the Sears schedule of not giving more than 2 at a time, though once we did 3, and coincidence or not, my daughter was SO ILL afterwards that I'll be careful to never do that again now that we're about to embark on it all over again with my son. It was really interesting to read your thoughts on this as an immunologist.

    I'm pro-vaccine, but that doesn't mean I have to agree with the CDC schedule, which (IMO) is highly influenced by trying to take care of the masses and make sure the children of less-responsible parents who are less likely to bring their children in for well child checks are still taken care of. I had a huge argument about this with a nurse at the family practice I work at - she's convinced it's best to give 5 at once (at 2 months old!) because it shocks the system "harder" and make the vaccination "work better." Um, No. I disagree. UGH. I'll stick to my 2 shots / time schedule and be happy with it...

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    1. Interesting about the two-shot versus three-shot thing. The results Orangesun quoted about multiple vaccines (two instead of one in that case) resulting in lower antibody levels and inappropriate immune responses is sort of logical and somewhat expected, if you think about it. Our immune systems in a natural setting usually do not have to battle two or more very strong bugs at the same time, they usually battle only one.

      And yes, all public policies are formed by people who have to consider the overall herd, rather than a select few. Yes, many parents want to take the easier route out, or are not as conscientious/thoughtful as some other parents. I guess this HAS to be factored in when designing public policy. But then again, who ever chooses to be thoughtful and looks for the most optimal/effective/safe way of doing things should be allowed to do so as well, without being criticized for it. It is all a very grey area, and the fact that both sides (the pro- and anti-CDC camps) can be so black and white is sad.

      As to the nurse who said "6 shots at one go make the vaccination "work better.": GOD. I wish she would atleast try to get better informed about the science before making such utterly ignorant, misleading statements.

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  13. Interesting. I spaced out my daughter's vaccines mostly because it seemed like overload to me, esp where live viruses were concerned. With my son, I followed the usual schedule set by his ped (though there might have been one exception in there?) mostly because I couldn't handle more doctor visits...which is a totally lame reason, I know.

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  14. Many congrats on 32 weeks and breast milk donation! I have a slightly off topic question that your post reminded me off. I get the flu shot every year because after having the flu every year I was over it. I do recognize that the formula is a best guess and not always the correct strain but so far so good. My question is I constatntly hear my friends and coworkers swear the flu shot did or has in the past given them the actual flu. My very basic knowledge says with a killed virus vaccine this is impossible. Can you help explain who is probably right and why? Your knowledge impresses and fascinates me. :-)

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    1. Aww, thanks :) I have not read up on this, but off the top of my head, I would say that they wouldn't really get the flu in that the virus would not be able to multiply and spread and truly cause an infection.

      However, the components of the dead/weakened (??) virus could stimulate the same symptoms (due to inflammation) as the live virus, but the people would not ever be in danger, per se, like you are when you have the flu and have something to fight off. They would, however, be miserable. The flu virus, dead or alive, has a tremendous capacity to cause inflammation (which can in part manifest as fever, body ache, all that fun stuff), so its probably one of the nastiest vaccines to take :-(

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  15. Congratulations on 32 weeks! Your friend's offer is incredibly kind! Wow, time's going by real fast ... I am so excited for you :))

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  16. Dr. Bob Sears is a quack. I say that as a pediatrician who has read the tripe in his two "vaccine books". All he has done is speculate--the man didn't actually do any clinical research or testing of his "schedule"--he just made it up out of thin air. Incidentally, it was one of "Dr. Bob's" own unvaccinated patients who caused the 2008 San Diego County measles outbreak (http://justthevax.blogspot.com/2011/04/2008-measles-in-dr-bob-sears-waiting.html), and you can be certain the cases of measles in the nearby schools of Temecula this February in unvaccinated children probably also are trackable to his faulty beliefs. If you follow "Dr. Bob", you do so at the peril of your child. --Chris Hickie, MD, PhD

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    1. Dr Hickie, I would advice you to read my post carefully, and also read the Nature Reviews Immunology article, as it is very important for physicians to atleast try to understand the differences in the humoral immune response in neonates and young infants versus that in babies over one year of age, as you seem to have completely missed the point I was trying to convey.

      I am *not* a fan of the delays in administering vaccines after one year of age, as proposed in Dr Sears's schedule. However, I'm horrified at the inefficiency of the regular schedule, because administering six vaccines containing more than eight antigens to a two-month-old baby with a fledgling B cell compartment could result in inefficient or worse inappropriate activation (tolerance or nonspecific immune responses) and and poor/no generation of memory B cells! The regular schedule may partially or utterly fail to protect my baby against pertussis because of the utter inefficiency of immunization protocol they have proposed, which is borne out by the fact that the DTAP vaccine does not seem to protect efficiently against whooping cough; babies given this vaccine still get sick: should I not be concerned about that? The thing that nobody seems to understand is that it may be really easy to improve the efficiency; wait about a month, and give it alone, or at beast, with only one more vaccine! This question needs to be addressed through research. However, instead of asking the right questions, both sides come up with irrelevant arguments while skirting the main issues.

      In summary, both the regular schedule and the Sears schedule have issues, The best vaccine strategy would be finding a middle ground, and not using a one-size-fits-all approach. This would require having a rational debate and not merely trashing your opponents view and calling them a quack. Sadly, seems like too much to ask for.

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