vaccinations: what parents need to know

8/8/2019 Vaccinations: What Parents Need to Know

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AMERICAN COUNCIL ON SCIENCE AND HEALTH1995 Broadway, 2nd Floor, New York, NY 10023-5860

Tel. (212) 362-7044 Fax (212) 362-4919URL: http://www.acsh.org E-mail: [email protected]

Vaccinations:What Parents Need to Know*

Prepared for the American Council on Science and Health

by Kathleen Meister, M.S.

Project CoordinatorGilbert L. Ross, M.D.Medical Director, ACSH

President

Elizabeth M. Whelan, Sc.D., M.P.H.

Art Director

Yelena Ponirovskaya

September 2003

* based on ACSHs special report The Promise of Vaccines: The Science and the

Controversy, by David R. Smith, M.D., President, Texas Tech University Health

Sciences Center, Lubbock, Texas


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THE AM ERICAN CO UN CIL O N SCIEN CE AN D HEALTH (AC SH) APPRE-

CIATES THE CO N TRIBUTIO N S O F THE REVIEW ERS N AM ED BELO W .

ACSH accepts unrestricted grants on the condition that it is solely responsible for the

conduct of its research and the dissemination of its work to the public. The organization

does not perform proprietary research, nor does it accept support from individual corpo-

rations for specific research projects. All contributions to ACSHa publicly funded

organization under Section 501(c)(3) of the Internal Revenue Codeare tax deductible.

Individual copies of this report are available at a cost of $5.00. Reduced prices for 10 or

more copies are available upon request.

Copyright 2003 by American Council on Science and Health, Inc.

This book may not be reproduced in whole or in part, by mimeograph or any other

means, without permission.

Dale J. Chodos, M.D.

Kalamazoo, Mich.

William H. Foege, M.D., M.P.H.

Rollins School of Public Health

Emory University

Atlanta, Ga.

Vincent A. Fulginiti, M.D.

University of Colorado

The Childrens Hospital

Bruce G. Gellin, M.D., M.P.H.

Vanderbilt University School of

Medicine

Nashville, Tenn.

Robert Heimer, Ph.D.

Yale School of Public Health

New Haven, Conn.

Donald A. Henderson, M.D., M.P.H.

Johns Hopkins Bloomberg School

of Public Health

Baltimore, Md.

Paul Offit, M.D.

Childrens Hospital of Philadelphia

Edgar J. Schoen, M.D.

Kaiser Permanente Medical Center

Oakland, Cal.

Ekhard E. Ziegler, M.D.

College of Medicine

University of Iowa


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Table of ContentsIntroduction

Routine Childhood Immunization and Disease RatesThe Diseases that Childhood Vaccines Prevent

Diphtheria

Tetanus

Wooping Cough

PolioMeasles

Mumps

Rubella

Chickenpox

Hepatitis BHib (Haemophilus Influenzae Type B) Disease

Pneumococcal Disease

Hepatitis A

Myths about Immunizations

Balancing Risks and BenefitsHow Vaccine Safety Is Evaluated

Specific Concerns about Vaccine Safety

SIDS (Sudden Infant Death Syndrome)

MMR Vaccine and Autism

Multiple SclerosisType 1 Diabetes

Influenza Vaccines and Guillain-Barr Syndrome

ThimerosalThe Future of Vaccines

Tables and Figures

Table 1: Recommended Childhood and AdolescentImmunization Schedule, 2003

Table 2: Universally Recommended Childhood Vaccinations

Table 3: Comparison of Maximum and Recent Morbidity

from Vaccine-Preventable Diseases and Vaccine

Adverse Events, United States, 1999Figure 1: Incidence of Invasive Hib Disease Among

Children


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I n t r o d u c t i o n

If you asked a group of parents to list their greatest concerns

about their childrens futures, you would get a variety of answers. Someparents would say that the quality of their childrens education is the

most important issue. Others might mention economic uncertainty, the

impact of new technology, or concerns about crime and violence. Its

unlikely, though, that any of the parents would say that their greatest

fear is that their children will die of an infectious disease before reach-ing adulthood. Yet if you had asked the same question a century ago,

infectious diseases would have been at the top of every parents list

and for good reason. At the beginning of the twentieth century, 16 out

of every 100 children died of infectious diseases before reaching the age

of five. Epidemics of highly contagious diseases such as diphtheria,polio, and whooping cough routinely killed large numbers of children

and left others with permanent disabilities.

Todays parents no longer fear these diseases. Some parents, how-

ever, have come to fear the vaccines that prevent them. Other parents

have become careless about having their children immunized becausethey dont realize that protection against infectious diseases is still

important. The very success of vaccines has made it difficult for people

to appreciate the true impact of immunization on childrens health.

When contagious diseases such as measles and whooping cough were

still common, people could easily understand why it was important tovaccinate their children against them. Modern parents often lack this

perspective.

This report from the American Council on Science and Health

(ACSH) based upon a special report written for ACSH by Dr. David

R. Smith, President of the Texas Tech Medical Center, a pediatricianand vaccine expert summarizes the evidence on both the benefits and

the potential risks of vaccines, with an emphasis on the vaccines used in

routine childhood immunization. The report addresses some of the com-

mon myths about vaccines and discusses some vaccine safety issues that

have recently been in the news.

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Routine Childhood Immunization and Disease Rates

Current guidelines call for children to receive routine immuniza-

tions against 11 diseases (12 in some parts of the country): diphtheria,

tetanus, pertussis (whooping cough), polio, measles, mumps, rubella

(German measles), chickenpox (varicella), hepatitis B,Haemophilus

influenzae type B disease (Hib), pneumococcal disease, and (in someparts of the country) hepatitis A. Table 1 shows the current schedule for

immunization against these diseases, and Table 2 lists the recommended

vaccines all infants, toddlers and children should get.

Routine childhood immunization has dramatically reduced the

number of cases of vaccine-preventable diseases. Table 3 compares themaximum number of cases of various diseases that occurred in the U.S.

each year before vaccines were introduced with the number of casesoccurring in 1999. For all of the diseases listed, immunization has led

to a decrease in the number of people who develop the disease of at

least 97 percent.

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This schedule indicates the recommended ages for routine administration of currently licensed childhood

vaccines, as of December 1, 2002, for children through age 18 years. Any dose not given at the recom-mended age should be given at any subsequent visit when indicated and feasible. Indicates age groups that

warrant special effort to administer those vaccines not previously given. Additional vaccines may be

licensed and recommended during the year. Licensed combination vaccines may be used whenever any

components of the combination are indicated and the vaccines other components are not contraindicated.

Providers should consult the manufacturers' package inserts for detailed recommendations.


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The Diseases that Childhood Vaccines Prevent

Many of the diseases that vaccines prevent have become so unfa-

miliar that parents may not realize why its important to protect children

against them. To understand why immunization is necessary, its helpfulto know something about these diseases and about the impact that they

had on Americas children before vaccines were developed. The

descriptions that follow are not pleasant, but they provide a necessary

perspective on the importance of immunization.

Diphtheria

Most Americans alive today have never seen a case of diphtheria.

Our great-grandparents, however, were terrified of it. Diphtheria is a

Vaccinations: W hat Parents N eed to Know

7

Population Vaccination Dosage

All young children Measles, mumps, rubella 2 doses

Diphtheria-tetanus toxoid

and pertussis vaccine 4 doses

Poliomyelitis 4 doses

Haemophilus influenzaetype b 4 doses

Hepatitis B 3 dose

Varicella 3 doses

PCV7 4 doses

Hepatitis A (in selectedareas) 2 doses

Previously unvac- Hepatitis B 3 doses

cinated or partially Varicella If no previous history of vaccinated adolescents varicella, 1 dose for chil-

dren aged < 12 years, 2

doses for children aged

13 years

Mumps, measles, 2 doses, totalrubella if not vaccinated during

previous 5 years, 1

combined booster during

ages 11-16 years


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very serious disease caused by a kind of germ called a bacterium. It can

cause a thick membrane to form in the throat, making it difficult or even

impossible for a child to swallow or breathe. The diphtheria bacteriumalso produces a toxin (poison), which can cause serious complications,

including heart and nerve damage. About 10 percent of all cases of

diphtheria are fatal. Before immunization began, diphtheria was a major

cause of illness and death in U.S. children. For example, in 1921,

206,000 cases of diphtheria and 15,520 deaths were reported.

Tetanus

Unlike the other vaccine-preventable diseases, tetanus is not spread

from person to person. Instead, it enters the body through breaks in the

skin. Deep puncture wounds are especially likely to become infected

Disease Maximum 1999* Percentage

Cases (Year) Change

Diphtheria 206,939 (1921) 1 -99.99

Measles 894,134 (1941) 86 -99.99

Mumps 152,209 (1968) 352 -99.76

Pertussis 265,269 (1934) 6,031 -97.63

Polio (wild) 21,269 (1952) 0 -100.00

Rubella 57,686 (1969) 238 -99.58

Cong. Rubella

Synd. 20,000* (19645) 3 -99.98Tetanus 1,560* (1948) 33 -97.88

Invasive HIB

Disease 20,000* (1984) 33 -99.83

Total 1639,066 6,777 -99.58

Vaccine Adverse

Events 0* 11,827**

Provisional totals of reported cases to the CDC.

* Estimated because no national reporting existed in the prevaccine era.** Adverse events after vaccines against diseases shown on table = 5,296


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with the tetanus bacterium.

Inside the body, the bacterium

produces a toxin (poison) thatcauses severe muscle spasms

(contractions). Approximately

30 percent of all cases of

tetanus are fatal. People who

survive tetanus may be leftwith lasting impairments in

speech, memory, and mental

function. In the 1920s, before

immunization became avail-

able, there were more than

1,000 cases of tetanus eachyear in the U.S. Today, there

are only about 40 cases a year.

Whooping Cough

Whooping cough (also

called pertussis) is a nasty,

prolonged illness in which

children may have severe

coughing spells for manyweeks. The spells can make it

difficult for a child to eat,

drink, or even breathe.Although whooping cough is a miserable experience for any child, it is

especially serious in infants, who may develop pneumonia, dehydration,seizures, and brain damage. Before immunization became available,

between 150,000 and 260,000 cases of this disease were reported each

year, with up to 9,000 deaths. Whooping cough still occurs today, with

over 7,000 cases reported in 1999. It still causes some deaths, especially

in young infants. Between 1990 and 1996, 57 people died from whoop-ing cough in the U.S.; 49 of them were under the age of 6 months.

Polio

Before a vaccine became available in 1955, polio was one of themost dreaded childhood diseases. In just a few days, this disease couldpermanently cripple a previously healthy child. Polio is caused by a

virus that lives in the throat and intestinal tract. Sometimes, this virus

causes a disease so mild that the person who catches it never realizes


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Ho w Vacc ines W o r kVaccines work by priming

the bodys immune system to

respond quickly and effectivelyto a particular disease-causing

virus or bacterium. A vaccinemay consist of a live but weak-

ened disease agent, a killeddisease agent, or a specificcomponent of the disease virus

or bacterium. The vaccine doesnot cause the disease, but it

tricks the immune system intoproducing antibodies or

immune cells that are capableof responding to the real dis-ease agent. If, at some later

time, the immunized person isexposed to the disease-caus-

ing virus or bacterium, thebodys defenses will be ready

to fight off the invader.


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that its polio. In other cases, however, polio causes paralysis that can

lead to permanent physical disability or death. Before immunization, an

average of 16,000 cases of paralytic polio were reported in the U.S.each year, and about 1,800 people per year died of this disease. There

were no reported cases in the U.S. in 1999.

Measles

Before measles vaccine became available in 1963, practicallyeveryone in the U.S. got this extremely contagious disease. At least half

a million cases of measles were officially reported each year, and

experts believe that the total number of cases was approximately 3 to 4

million annually. For the majority of children who contract measles, the

disease is relatively mild, with a fever, a rash, and symptoms resem-

bling those of a cold. Some children, however, become seriously ill.About one in five children with measles need to be hospitalized, one in

20 develops pneumonia, and one in 1,000 develops encephalitis (an

inflammation of the brain that can cause convulsions and lead to perma-

nent deafness or brain damage). During each of the 10 years just beforethe development of measles vaccine, about 1,000 Americans developed

permanent brain damage or deafness as a result of measles, and over

500 died of the disease. Worldwide, measles still kills almost a million

people each year, primarily in developing countries where immuniza-

tion is not readily available. But in the U.S. in 1999, there were onlyabout 100 cases reported.

MumpsBefore a vaccine became available, mumps was a common child-

hood disease. Most cases of this disease are mild, with fever, headache,and swelling of the cheeks and jaw, caused by inflammation of the sali-

vary glands. In some instances, though, mumps can lead to serious

complications. About one child in every 10 who get mumps also gets

meningitis, and about one in every four adult men or teenage boys who

get mumps develops a painful swelling of the testicles. In rare cases,mumps can cause deafness, encephalitis (brain inflammation), or male

sterility. One case in 10,000 is fatal. While at its peak there were well

over 100,000 cases, in 1999 only 350 were reported.

Rubella

Rubella (also called German measles and three-day measles)

is almost always a mild illness in children. It causes a slight fever that

lasts a day or so and a rash that lasts for two or three days. Rubella can


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be disastrous, however, to unborn babies. If a woman gets rubella dur-

ing the early months of her pregnancy, there is at least an 80 percent

chance that her baby will be born with serious, permanent health prob-lems, such as heart defects, blindness, deafness, or mental retardation.

This condition is called congenital rubella syndrome (CRS). In 1964-65,

before rubella vaccine was widely available in the U.S., more than 12

million Americans developed rubella during a major epidemic, and

20,000 infants were born with CRS. About 11,600 of these childrenwere deaf, 3,580 were blind, and 1,800 were mentally retarded. In 1999,

however, less than 100 such cases were reported.

Chickenpox

Chickenpox (also called varicella) is a very common and very

contagious disease. Prior to the availability of chickenpox vaccine, prac-tically everyone contracted chickenpox, for a total of about 4 million

cases per year. Most cases of

chickenpox are mild, with an

itchy rash and sometimes afever. In rare cases, however,

chickenpox can be serious.

About one child out of 500

(and one adult in 50) who gets

chickenpox must be hospital-ized. Of 100,000 children who

get chickenpox, one will die of

the disease. In infants, thedeath rate is higher about

four in 100,000. Prior toimmunization, there were

about 100 deaths from chick-

enpox in the U.S. each year.

While these numbers are much

lower now, there are not yetexact statistics available on

recent infection and complica-

tion rates since vaccination has

been widely used.

Hepatitis B

Hepatitis B is a liver dis-

ease caused by a virus. Some


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W hat Ab out Yo u ?

Immunization isnt just forchildren. It can also play an

important role in protectingadults against infectious dis-eases. Unfortunately, though,

many adults dont get the"shots" that they need.

All adults should have a

tetanus-diphtheria booster shotevery ten years. Older peopleshould also receive a singleimmunization against pneumo-

coccal disease and an annualflu shot. Some adults may need

additional immunizations, espe-cially if they are members of

groups at high risk for a partic-ular disease. For example, peo-ple who have multiple sex part-

ners should be immunizedagainst hepatitis B.

Have you had all yourshots? If youre not sure,check with your doctor.


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people who develop this disease recover completely, but others develop

a long-term (chronic) hepatitis B infection. People with chronic hepati-

tis B often carry the virus in their blood for the rest of their lives. Theycan infect other people, and they may develop severe liver problems,

such as cirrhosis or liver cancer, as a result of their prolonged infection.

It is also important to diagnose hepatitis B in pregnancy, so that the

newborn can be given protective immunization to prevent mother-to-

child transmission. Of the 1.25 million people in the U.S. who havechronic hepatitis B infection, about 4,000-5,000 die from related liver

diseases each year.

Hib (Haemophilus influenzae Type B) Disease

Despite its name, Haemophilus influenzae type B does not cause

influenza. But it does cause other serious illnesses, including meningi-tis, in infants and young children. Before a vaccine became available in

the early 1990s, there were approximately 20,000 cases of Hib diseases

each year; approximately two-thirds were meningitis, and the other one-

third were other conditions such as pneumonia, bacteremia (bacterialinfection of the bloodstream), or epiglottitis (a severe throat infection

that can cause death from suffocation). Meningitis due to Hib caused

600 deaths each year, and many children who survived the disease were

left with permanent problems, such as deafness, seizures, or mental

retardation. In 1999, there were under 80 such cases.

Pneumococcal Disease

Like Hib, the pneumococcus bacterium can cause meningitis andother severe illnesses, including pneumonia and blood infections. The

groups at highest risk for pneumococcal disease are elderly people andvery young children. Each year in the U.S., about 16,500 children under

the age of five develop pneumococcal disease, including approximately

1,000 who develop meningitis. About 200 children die. A vaccine

against the pneumococcal bacterium has long been available for adults,

but that vaccine doesnt work well in children. Very recently, a newtype of pneumococcal vaccine that does work in children has become

available, and it is now recommended as one of the routine immuniza-

tions for all children under the age of two.

Hepatitis A

Like hepatitis B, hepatitis A is a liver disease. Hepatitis A is the

most common type of hepatitis reported in the U.S., with an estimated

125,000 cases each year. Unlike hepatitis B, hepatitis A does not cause


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long-term infection. However, it can be a serious or even fatal disease.

About 100 Americans die from liver failure due to hepatitis A each year.

A vaccine against hepatitis A is available for children age two years andolder. It is recommended as part of the routine immunizations for chil-

dren in the Western states, where rates of this disease are highest, and

for members of certain other high-risk communities.

M yths ab out Immuniza tions

People sometimes believe that childhood infectious diseases are

things of the past, and that vaccination is no longer necessary. This is a

myth. The viruses and bacteria that cause vaccine-preventable diseasesstill exist and cause disease. If immunization rates are allowed to

decrease, these now-rare diseases will come back.This happened in the U.S. a little more than a decade ago. Due to

a combination of parental apathy and increasing abuse of philosophi-

cal and religious exemptions from vaccination, during the late 1980s,measles vaccination rates decreased. As a result, in 1989-91, a large out-

break of measles occurred, with more than 43,000 cases and more than

100 deaths. Only a few hundred cases would have been expected. The

decreased coverage rate for measles led to an increased susceptibility

for the entire community, and the epidemic resulted, striking mainlyunvaccinated infants in the inner cities.

Other industrialized nations have had similar experiences. For

example, levels of immunization against pertussis (whooping cough)

dropped in both the United Kingdom and Japan during the 1970s.

Within a few years, large outbreaks of pertussis occurred in both coun-tries, with more than 100,000 cases and 36 deaths in the U.K. and more

than 13,000 cases and 41 deaths in Japan.

Pertussis and measles arent the only vaccine-preventable diseases

that wont disappear. Tetanus is also here to stay. The bacterium that

causes this disease is widespread in the environment. Its found in soiland street dust, and its resistant to heat and chemicals. Although tetanus

is a very rare disease, immunization is still necessary, and it probably

always will be.

Even diseases that are virtually unknown in the U.S.such as

polio or diphtheria could return if they were reintroduced into thiscountry by travelers from other parts of the world. (Infectious disease

experts like to point out that even the most exotic diseases are only a

plane ride away.) In 1994, polio was introduced into Canada from India,

but it didnt spread in the North American population because immu-


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nization levels were high. In the early 1990s, a major outbreak of diph-

theria occurred in the countries of the former Soviet Union, with more

than 150,000 cases and 5,000 deaths. This epidemic was caused by abreakdown in public health services, with an accompanying decrease in

immunization rates. If diphtheria immunization were discontinued in

the U.S., a similar situation could occur here.

Another myth about vaccines is that they arent needed because

improvements in sanitation and nutrition had caused disease rates todrop even before vaccines were introduced. While it is true that general

improvements in living conditions have helped to reduce disease rates,

immunizations have caused an additional, sustained reduction in dis-

ease. Moreover, such reductions are just as evident for vaccines intro-

duced in recent decades, when high standards of sanitation and nutrition

were well established, as they were for vaccines introduced in earliertimes. The experience with Hib disease, illustrated in Figure 1, is a

good example. The rate of Hib disease dropped dramatically after

immunization was introduced in the late 1980s, and it remained low

throughout the 1990s. Yet standards of hygiene in the mid-1990s werenot appreciably different from those that existed a decade earlier.

A third myth is that parents who choose religious or philosophical

exemptions from routine childhood vaccinations are risking only their

childrens health, not anyone elses. The truth is that these people are

risking the health of other members of their families and communitiesas well. When the proportion of a population that is immunized against

a disease is high, the spread of the disease through the community may

*Rate per 100,000 children


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stop, even though some individuals are not immunized. This phenome-

non is called community immunity. If coverage falls to a level where

transmission of the disease agent resumes, community immunity is lost,and people who are not immune to the disease are put at risk. Thus,

children who dont receive their routine vaccines endanger others. The

people who are put at risk include those too young to have been immu-

nized, those who cannot receive the vaccine for medical reasons (e.g.,

people who are severely allergic to vaccine components), and peoplewho received the vaccine but did not respond to it. (Vaccines are not

100 percent effective; a small percentage of people who receive a vac-

cine do not develop immunity.)

Balancing Risks and Benefits

Like all pharmaceutical products, vaccines can produce side effects. The

most common side effects are minor ones: soreness at the injection site

or low-grade fever. Serious side effects from immunizations are veryrare.

When evaluating the safety of a vaccine, its necessary to consider

both the risk of side effects and the benefits of immunization. Or, to put

it another way, the risks associated with receiving the vaccine should be

compared with the risks associated with not receiving it. For all of thevaccines recommended today, the risks associated with the vaccine are

far lower than the risks associated with not receiving it and therefore

remaining susceptible to the disease.

For example, approximately one out of every 30,000 people who

receives MMR (measles-mumps-rubella) vaccine develops thrombocy-topenia (an abnormally low platelet count). This condition is temporary

and usually causes no major problems, but in some instances it leads to

abnormal bleeding. Two of the diseases that the vaccine protects

against, measles and rubella, can also cause thrombocytopenia, and the

risk of this complication is much greater during the actual illness than itis after vaccination. If MMR vaccination were discontinued, practically

everyone would get measles and many people would also get rubella.

The number of people who would develop thrombocytopenia as a result

of these diseases would be far greater than the number who currently

develop it as a result of immunization.Official decisions about what vaccines to use are based on careful

considerations of risks and benefits. A recent change in polio vaccina-

tion recommendations in the U.S. was based on just this sort of evalua-

tion. There are two kinds of polio vaccine: oral polio vaccine (OPV)


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and inactivated polio vaccine (IPV). Both protect against polio, but

OPV is more effective in preventing the spread of the disease from one

person to another. OPV has an important disadvantage, however. Inextremely rare instances (about 1 in 2.4 million), OPV actually causes

polio. IPV, which is made from a killed virus, cannot cause polio. For

many years, practically all American children received OPV. However,

since the risk of getting polio in the U.S. is now extremely low, experts

believe that the use of OPV is no longer worth the slight risk associatedwith it. As of January 2000, official guidelines in the U.S. call for the

use of IPV, except in very limited circumstances. In some other parts of

the world, however, where the risk of polio is much higher, OPV is still

the preferred vaccine.

How Vaccine Safety Is Evaluated

The safety of vaccines is monitored both before and after they go

on the market. Like all drugs, vaccines must be approved and licensedby the Food and Drug Administration (FDA) before they can be sold.

The FDA requires new vaccines to be evaluated for safety and efficacy

in laboratory studies and in three different phases of clinical trials in

human volunteers. The clinical trials, which typically involve several

thousand or more people, can identify common side effects of the vac-cine and provide an estimate of how often these effects occur. Rare side

effects are not likely to be discovered, however, until after the vaccine

is marketed.

To identify rare side effects, FDA and the federal Centers for

Disease Control and Prevention (CDC) have set up a system called theVaccine Adverse Event Reporting System (VAERS), which collects

information from physicians, manufacturers, and others about any

unusual events that occurred after vaccination. If VAERS data or infor-

mation from other sources suggest that some type of risk may exist, for-

mal scientific studies are conducted to assess the potential risk.Its important to note that events that occur after vaccination are

not necessarily caused by vaccination. They may merely be coinci-

dences. For example, suppose you heard of a case in which an infant

received immunizations in the morning and then died of Sudden Infant

Death Syndrome (SIDS) later the same day. Would you think that theimmunizations had caused the death? Many people would. However,

the two events are not necessarily linked. Every year in the U.S., nearly

5,000 infants die of SIDS, usually between the ages of 1 and 4 months.

Practically all infants receive immunizations at least once during those

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months. By sheer coincidence, some of the infants who die of SIDS will

have received immunizations shortly before their deaths. In fact,

approximately 50 cases of SIDS (roughly 1 in 100) will occur each yearwithin 24 hours of vaccination by chance alone.

Individual case reports (such as the report that a physician would

submit to VAERS if an infant died of SIDS shortly after being immu-

nized) cannot distinguish

between coincidences andcause-and-effect relationships.

To make this distinction, scien-

tists must conduct studies

involving large groups of peo-

ple. Researchers compare the

experiences of groups whoreceived the vaccine with

those of groups who did not.

They look at data from differ-

ent time periods to see whatchanges may have occurred

after a new vaccine was intro-

duced. They consider all the

alternative explanations for

any patterns that they observe.Health officials then use the

data and analyses as the basis

for decisions about whether ornot to recommend the use of a

particular vaccine.The recent experience

with rotavirus vaccine illus-

trates the way that this system

works. Rotavirus causes severe

diarrhea in children andaccounts for more than

500,000 physician visits and

50,000 hospitalizations in the

U.S. each year (and this dis-ease is even more devastatingin the underdeveloped world).

In August 1998, a vaccine

against this virus became


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The Disease that

N o Long er Exists

If you were born before

the 1970s, you almost certainlyreceived a vaccine against

smallpox one of the deadliestdiseases the world has ever

known. Todays children, how-ever, do not need to be immu-nized against smallpox. Thanks

to an extraordinary globalimmunization campaign, this

disease no longer exists innature. It is the first and so

far the only disease to betruly eradicated worldwide.Health authorities hope, how-

ever, that smallpox wont retainits unique status much longer.

A campaign to eradicate polioworldwide is now in progress

and may reach its goal withinthe next few years.

(Note: the necessity of

re-instituting large-scale small-pox vaccination was consid-

ered recently, due to threats ofbioterrorist use of smallpox

virus as a weapon. Focusedvaccination of armed forces,

health-care workers, and firstresponders was initiated inearly 2003 but suspended

again a few months later.)


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available, and doctors began to administer it to infants. Within the next

few months, VAERS received reports indicating that about 15 infants

had developed intussusception (a rare condition in which one segmentof the intestine telescopes into another, sometimes leading to intestinal

blockage) shortly after receiving rotavirus vaccine. Although the num-

ber of cases of intussusception was very small in comparison with the

number of infants who had received the vaccine, analysis of the VAERS

reports and other data suggested that the vaccine might indeed be asso-ciated with an increase in the risk of this rare problem. Therefore, the

use of rotavirus vaccine was discontinued in the U.S. in October 1999

pending further study.

Specif ic Concerns about Vaccine Safety

Several concerns about safety aspects of various vaccines have

been raised in recent years. Three such issues have already been men-

tioned in this report: the basis for the recent change in the type of poliovaccine recommended for U.S. children is discussed on page 16 the

relationship between MMR vaccine and thrombocytopenia is explained

on page 15; and the withdrawal of rotavirus vaccine is discussed in the

preceding section. The following sections summarize other vaccine

issues that have been in the news.

SIDS (Sudden Infant Death Syndrome)

As mentioned earlier in this report, since practically all infants

receive immunizations, it is inevitable that some of the infants who die

of SIDS will have received immunizations shortly before their deaths.This is a matter of chance, not a cause-and-effect relationship. There is

no evidence that any vaccine actually causes or contributes to SIDS.

There is also no evidence that any vaccine protects against SIDS,

although a casual look at statistical data might seem to suggest other-

wise.Between the years 1992 and 1996, routine childhood immuniza-

tion with hepatitis B vaccine was introduced in the U.S., and the pro-

portion of young children who received this vaccine increased dramati-

cally. During the same time period, the rate of SIDS dropped just as

dramatically. The similarity in the two time trends is striking, but it ismerely a coincidence. The real cause of the decrease in SIDS was a

campaign to teach parents to put infants to sleep on their backs, which

began in the early 1990s. The hepatitis B vaccine did not play a role.

1 8


19/24

MMR Vaccine and Autism

A great deal of public attention has recently focused on the sus-

pected link between the MMR (measles-mumps-rubella) vaccine andautism. (Autism is a developmental disorder characterized by impaired

communication and social interaction, with repetitive activities that fur-

ther restrict social interactions. It is estimated to occur in about two of

every 1,000 children.) This concern was first raised in 1998, when

British researchers published a study that seemed to show an associa-tion. That initial study, however, was based on only 12 children.

Subsequent studies of much larger groups of children have not con-

firmed an association and have not demonstrated the patterns of change

that would be expected if MMR and autism were truly linked. For

example, a larger British study showed that the number of cases of

autism had been increasing since 1979, with no jump after the introduc-tion of MMR vaccine in 1988. A study in California showed that the

MMR vaccination rate had increased there for several years and then

leveled off, while autism rates increased steadily during the same years.

If MMR and autism were linked, one would expect that the rates of vac-cine coverage and autism would parallel one another. But in these and

other studies, that pattern has not been observed.

Several other recent studies have confirmed the lack of any associ-

ation between autism and MMR vaccine. MMR is usually given

between the ages of 12 and 15 months. Symptoms of autism oftenbecome evident just a few months later, when parents or professionals

notice that a childs language development is not proceeding normally.

For this reason, it is likely that some children will be diagnosed withautism shortly after receiving MMR vaccine. There is no scientific evi-

dence to support the notion that the vaccine causes the disorder.

Multiple Sclerosis

Several reports in medical journals have described individual cases

in which a patient developed symptoms of multiple sclerosis (MS)

shortly after immunization. These reports have raised concerns that vac-cines (especially hepatitis B vaccine) might be linked to this disease.

Individual case reports cannot distinguish between coincidences and

cause-and-effect relationships, however. Studies of larger groups of peo-

ple have not detected any association between immunization and theonset of MS.The cases in which individuals developed symptoms of MS shortly

after receiving hepatitis B vaccine are almost certainly coincidental. In

recent years, physicians have encouraged young adults, especially those


1 9


20/24

who have risk factors for hepatitis B, to be vaccinated against this dis-

ease. Young adulthood is the time when MS is most often diagnosed.

Thus, simply by coincidence, some young people who receive hepatitisB vaccine may develop MS shortly thereafter.

Type 1 Diabetes

The cause of type 1 diabetes (the type that often begins in childhood) is

not known. A variety of possible causal factors have been suggested,including immunizations. However, analyses of the relationship of vac-

cinations to type 1 diabetes in humans have not found any causal link.

Influenza Vaccines and Guillain-Barr Syndrome

The swine flu vaccine administered during 1976-77 was associated

with a significant increase in the risk of Guillain-Barr syndrome (arare neurological complication involving paralysis that is usually

reversible). Other influenza vaccines, however, have not been associat-

ed with a similar risk. Outside of 1976, the increased risk for Guillain-

Barr syndrome associated with influenza vaccination has been nogreater than one case per million individuals vaccinated. This is much

less than the risk of developing a serious complication from influenza

itself.

Thimerosal

Thimerosal is a preservative that has been included in some vac-

cines since the 1930s to help prevent bacterial contamination. Concerns

have been raised about the use of thimerosal because it contains mercu-ry. There is no evidence, however, that thimerosal has caused any

health problems in children. Problems have not been found even in pre-mature infants (who would be at highest risk because they would

receive the most thimerosal in relation to their body weight).

Nevertheless, despite the absence of scientific evidence linking

thimerosal to any disease, because the overall exposure of children to

mercury is a public health concern, it was decided in 1999 to switch tovaccines that do not contain thimerosal preservative. As of 2002,

thimerosal has been removed from commonly administered pediatric

vaccines. (For diphtheria-tetanus-pertussis, hepatitis B, and Hib vac-

cines, this reflects a change; the measles-mumps-rubella, chickenpox,inactivated polio, and pneumococcal vaccines never containedthimerosal.)

In the unlikely event that parents discover that the preservative-

free version of a vaccine is not yet available from their health care

2 0


21/24

provider, or if a child needs to receive a special type of vaccine that is

not available in a preservative-free formulation (e.g., influenza vaccine

for certain children with chronic diseases), they should notdelay orrefuse the vaccination. The very real risk of disease associated with fail-

ure to immunize far outweighs the purely theoretical risk associated

with exposure to thimerosal preservative.

The Future o f Va c c i n e s

Immunization is one of the most effective weapons in the modern

medical arsenal. This approach to disease prevention is likely to become

even more important in the future, as new technologies allow more andbetter vaccines to be developed. Experts have projected that the number

of vaccines in widespread use will triple in the next 20 years. New vac-cines may be especially helpful in the fight against diseases caused by

bacteria that have developed resistance to antibiotics.

Vaccines have done more to protect children against death and disabilityfrom infectious diseases than any other public health intervention.

However, the war against these diseases is not over. Worldwide, it is

estimated that over two million children die annually from infectious

diseases that could have been prevented by immunization. Even in the

U.S., several hundred children a year die from vaccine-preventable dis-eases. To prevent these tragedies and keep infectious diseases under

control, parents and health care professionals should make every effort

to ensure that all children receive the proper immunizations, both for

their own protection and for the protection of the community as a

whole.


2 1


22/24

Elizabeth M. Whelan, Sc.D., M.P.H.President

A C S H B O A R D O F D I R E C T O R S

John H. Moore, Ph.D., M.B.A.Chairman of the Board, ACSHGrove City College

Elissa P. Benedek, M.D.

University of MichiganNorman E. Borlaug, Ph.D.Texas A&M University

Michael B. Bracken, Ph.D., M.P.H.Yale University School of Medicine

Christine M. Bruhn, Ph.D.University of California

Taiwo K. Danmola, C.P.A.Ernst & Young

Thomas R. DeGregori, Ph.D.University of Houston

Henry I. Miller, M.D.Hoover Instit ution

A. Alan Moghissi, Ph.D.Institute for Regulatory Science

Albert G. NickelLyons Lavey Nickel Swift, inc.

Kenneth M. Prager, M.D.Columbia College of Physicians and Surgeons

Stephen S. Sternberg, M.D.Memorial Sloan-Kettering Cancer Center

Mark C. Taylor, M.D.Physicians for a Smoke-Free Canada

Lorraine ThelianKetchum Public Relations

Kimberly M. Thompson, Sc.D.Harvard School of Public Health

Elizabeth M. Whelan, Sc.D., M.P.H.American Council on Science and Health

Robert J. White, M.D., Ph.D.Case Western Reserve University

A C S H B O A R D O F S C I EN T I F I C A N D P O L I C Y A D V I S O R S

Ernest L. Abel, Ph.D.C.S. Mott Center

Gary R. Acuff, Ph.D.Texas A&M University

Alwynelle S. Ahl, Ph.D., D.V.M.Tuskegee University, AL

Julie A. Albrecht, Ph.D.University of Nebraska, Lincoln

James E. Alcock, Ph.D.Glendon College, York University

Thomas S. Allems, M.D., M.P.H.San Francisco, CA

Richard G. Allison, Ph.D.American Society for Nutritional Sciences(FASEB)

John B. Allred, Ph.D.Ohio State University

Philip R. Alper, M.D.University of California, San Francisco

Karl E. Anderson, M.D.University of Texas, Medical Branch

Dennis T. AveryHudson Institute

Ronald Bachman, M.D.Kaiser-Permanente Medical Center

Robert S. Baratz, D.D.S., Ph.D., M.D.International Medical ConsultationServices

Nigel M. Bark, M.D.Albert Einstein College of Medicine

Stephen Barrett, M.D.Allentown, PA

Thomas G. Baumgart ner, Pharm.D.,M.Ed.University of Florida

W. Lawrence Beeson, Dr.P.H.Loma Linda University School of Public

Health

Barry L. Beyerstein, Ph.D.Simon Fraser University

Steven Black, M.D.Kaiser-Permanente Vaccine Study Center

Blaine L. Blad, Ph.D.University of Nebraska, Lincoln

Hinrich L. Bohn, Ph.D.University of Arizona

Ben Bolch, Ph.D.Rhodes College

Joseph F. Borzelleca, Ph.D.Medical College of Virginia

Michael K. Botts, Esq.Ames, IA

George A. Bray, M.D.Pennington Biomedical Research Center

Ronald W. Brecher, Ph.D., C.Chem.,DABTGlobalTox International Consultants, Inc.

Robert L. Brent, M.D., Ph.D.Alfred I. duPont Hospital for Children

Allan Brett, M.D.University of South Carolina

Kenneth G. Brown, Ph.D.KBinc

Gale A. Buchanan, Ph.D.University of Georgia

George M. Burditt, J.D.Bell, Boyd & Lloyd LLC

Edward E. Burns, Ph.D.Texas A&M University

Francis F. Busta, Ph.D.University of Minnesota

Elwood F. Caldwell, Ph.D., M.B.A.University of Minnesota

Zerle L. Carpenter, Ph.D.Texas A&M University System

C. Jelleff Carr, Ph.D.Columbia, MD

Robert G. Cassens, Ph.D.University of Wisconsin, Madison

Ercole L. Cavalieri, D.Sc.University of Nebraska Medical Center

Russell N. A. Cecil, M.D., Ph.D.Albany Medical College

Rino Cerio, M.D.Barts and The London Hospital Instituteof Pathology

Morris E. Chafetz, M.D.Health Education Foundation

Bruce M. Chassy, Ph.D.University of Illinois, Urbana-Champaign

Dale J. Chodos, M.D.Kalamazoo, MI

Martha A. Churchill, Esq.Milan, MI

Emil William Chynn, M.D.Manhattan Eye, Ear & Throat Hospital

Dean O. Cliver, Ph.D.University of California, Davis

F. M. Clydesdale, Ph.D.University of Massachusetts

Donald G. Cochran, Ph.D.Virginia Polytechnic Institute and StateUniversity

W. Ronnie Coffman, Ph.D.Cornell University

Bernard L. Cohen, D.Sc.University of Pittsburgh

John J. Cohrssen, Esq.Public Health Policy Advisory Board

Neville Colman, M.D., Ph.D.St. Lukes Roosevelt Hospital Center

Gerald F. Combs, Jr., Ph.D.Cornell University

Michael D. Corbett, Ph.D.Omaha, NE

Morton Corn, Ph.D.John Hopkins University

Nancy Cotugna, Dr.Ph., R.D., C.D.N.University of Delaware

Roger A. Coulombe, Jr., Ph.D.Utah State University

H. Russell Cross, Ph.D.Future Beef Operations, L.L.C.

James W. Curran, M.D., M.P.H.Emory University

Charles R. Curtis, Ph.D.Ohio State University

Ilene R. Danse, M.D.Novato, CA

Ernst M. Davis, Ph.D.University of Texas, Houston

Harry G. Day, Sc.D.Indiana University

Robert M. Devlin, Ph.D.University of Massachusetts

Seymour Diamond, M.D.Diamond Headache Clinic

Donald C. Dickson, M.S.E.E.Gilbert, AZ

John DieboldThe Diebold Institute for Public PolicyStudies

Ralph Dittman, M.D., M.P.H.Houston, TX

John E. Dodes, D.D.S.National Council Against Health Fraud

Sir Richard Doll, M.D., D.Sc., D.M.University of Oxford

John Doull, M.D., Ph.D.University of Kansas

Theron W. Downes, Ph.D.Michigan State University

Michael Patrick Doyle, Ph.D.University of Georgia

Adam Drewnowski, Ph.D.University of Washington

Michael A. Dubick, Ph.D.U.S. Army Institute of Surgical Research

Greg Dubord, M.D., M.P.H.RAM Institute

Edward R. Duffie, Jr., M.D.Savannah, GA

David F. Duncan, Dr.Ph.Duncan & Associates

James R. Dunn, Ph.D.Averill Park, NY

Robert L. DuPont, M.D.Institute for Behavior and Health, Inc.

Henry A. Dymsza, Ph.D.University of Rhode Island

Michael W. Easley, D.D.S., M.P.H.State University of New York, Buffalo

J. Gordon Edwards, Ph.D.San Jos State University

George E. Ehrlich, M.D., F.A.C.P.,

M.A.C.R., FRCP (Edin)Philadelphia, PA

Michael P. Elston, M.D., M.S.Rapid City Regional Hospital

William N. Elwood, Ph.D.Center for Public Health & EvaluationResearch

James E. Enstrom, Ph.D., M.P.H.University of California, Los Angeles

Stephen K. Epstein, M.D., M.P.P.,FACEPBeth Israel Deaconess Medical Center

Myron E. Essex, D.V.M., Ph.D.Harvard School of Public Health

Terry D. Etherton, Ph.D.Pennsylvania State University

R. Gregory Evans, Ph.D., M.P.H.St. Louis University Center for the Studyof Bioterrorism and Emerging Infections

William Evans, Ph.D.University of Alabama

Daniel F. Farkas, Ph.D., M.S., P.E.Oregon State University

Richard S. Fawcett, Ph.D.Huxley, IA

John B. Fenger, M.D.Phoenix, AZ

Owen R. Fennema, Ph.D.University of Wisconsin, Madison

Frederick L. Ferris, III, M.D.National Eye Institute

David N. Ferro, Ph.D.University of Massachusetts

Madelon L. Finkel, Ph.D.Cornell University Medical College

Jack C. Fisher, M.D.University of California, San Diego

Kenneth D. Fisher, Ph.D.Washington, DC

Leonard T. Flynn, Ph.D., M.B.A.Morganville, NJ

William H. Foege, M.D., M.P.H.Emory University

Ralph W. Fogleman, D.V.M.Doylestown, PA

Christopher H. Foreman, Jr., Ph.D.University of Maryland

E. M. Foster, Ph.D.University of Wisconsin, Madison

F. J. Francis, Ph.D.

University of MassachusettsGlenn W. Froning, Ph.D.University of Nebraska, Lincoln

Vincent A. Fulginiti, M.D.University of Colorado

Arthur Furst, Ph.D., Sc.D.University of San Francisco

Robert S. Gable, Ed.D., Ph.D., J.D.Claremont Graduate University

Shayne C. Gad, Ph.D., D.A.B.T., A.T.S.Gad Consulting Services

William G. Gaines, Jr., M.D., M.P.H.Scott & White Clinic

Charles O. Gallina, Ph.D.Professional Nuclear Associates

Raymond Gambino, M.D.Quest Diagnostics Incorporated

Randy R. Gaugler, Ph.D.Rutgers University

J. Bernard L. Gee, M.D.Yale University School of Medicine

K. H. Ginzel, M.D.

University of Arkansas for Medical SciencesWilliam Paul Glezen, M.D.Baylor College of Medicine

Jay A. Gold, M.D., J.D., M.P.H.Medical College of Wisconsin

Roger E. Gold, Ph.D.Texas A&M University

Rene M. Goodrich, Ph.D.University of Florida

Frederick K. Goodwin, M.D.

The George Washington UniversityMedical Center

Timothy N. Gorski, M.D., F.A.C.O.G.Arlington, TX

Ronald E. Gots, M.D., Ph.D.International Center for Toxicology and

Medicine

Henry G. Grabowski, Ph.D.Duke University

James Ian Gray, Ph.D.Michigan State University

William W. Greaves, M.D., M.S.P.H.Medical College of Wisconsin

Kenneth Green, D.Env.Reason Public Policy Institute

Laura C. Green, Ph.D., D.A.B.T.Cambridge Environmental, Inc.

Saul Green, Ph.D.Zol Consultants

Richard A. Greenberg, Ph.D.Hinsdale, IL

Sander Greenland, Dr.P.H., M.A.UCLASchool of Public Health

Gordon W. Gribble, Ph.D.Dartmouth College

William Grierson, Ph.D.University of Florida

Lester Grinspoon, M.D.Harvard Medical School

F. Peter Guengerich, Ph.D.Vanderbilt University School of Medicine

Caryl J. Guth, M.D.Hillsborough, CA

Philip S. Guzelian, M.D.University of Colorado

Alfred E. Harper, Ph.D.University of Wisconsin, Madison

Terryl J. Hartman, Ph.D., M.P.H., R.D.The Pennsylvania State University

Clare M. Hasler, Ph.D.University of Illinois at Urbana-Champaign

Robert D. Havener, M.P.A.Sacramento, CA

Virgil W. Hays, Ph.D.University of Kentucky

Cheryl G. Healton, Dr.PH.Columbia University

Clark W. Heath, Jr., M.D.American Cancer Society

Dwight B. Heath, Ph.D.Brown University

Robert Heimer, Ph.D.Yale School of Public Health

Robert B. Helms, Ph.D.American Enterprise Institute

Zane R. Helsel, Ph.D.Rutgers University, Cook College

Donald A. Henderson, M.D., M.P.H.Johns Hopkins University

James D. Herbert, Ph.D.MCP Hahnemann University

Gene M. Heyman, Ph.D.McLean Hospital/Harvard Medical School

Richard M. Hoar, Ph.D.Williamstown, MA

Theodore R. Holford, Ph.D.Yale University School of Medicine

A C S H E X E C U T I V E S T A F F


23/24

Robert M. Hollingworth, Ph.D.Michigan State University

Edward S. Horton, M.D.Joslin Diabetes Center

Joseph H. Hotchkiss, Ph.D.

Cornell UniversitySteve E. Hrudey, Ph.D.University of Alberta

Susanne L. Huttner, Ph.D.University of California, Berkeley

Robert H. Imrie, D.V.M.Seattle, WA

Lucien R. Jacobs, M.D.University of California, Los Angeles

Alejandro R. Jadad, M.D., D.Phil.,

F.R.C.P.C.University of Toronto, Canada

Rudolph J. Jaeger, Ph.D.Environmental Medicine, Inc.

William T. Jarvis, Ph.D.Loma Linda University

Michael Kamrin, Ph.D.Michigan State University

John B. Kaneene,Ph.D., M.P.H., D.V.M.Michigan State University

P. Andrew Karam, Ph.D., CHPUniversity of Rochester

Philip G. Keeney, Ph.D.Pennsylvania State University

John G. Keller, Ph.D.Olney, MD

Kathryn E. Kelly, Dr.P.H.Delta Toxicology

George R. Kerr, M.D.University of Texas, Houston

George A. Keyworth II, Ph.D.Progress and Freedom Foundation

Michael Kirsch, M.D.Highland Heights, OH

John C. Kirschman, Ph.D.Emmaus, PA

Ronald E. Kleinman, M.D.Massachusetts General Hospital

Leslie M. Klevay, M.D., S.D.in Hyg.University of North Dakota School ofMedicine

David M. Klurfeld, Ph.D.Wayne State University

Kathryn M. Kolasa, Ph.D., R.D.

East Carolina UniversityJames S. Koopman, M.D, M.P.H.University of Michigan

Alan R. Kristal, Dr.P.H.Fred Hutchinson Cancer Research Center

David Kritchevsky, Ph.D.The Wistar Institute

Stephen B. Kritchevsky, Ph.D.Wake Forest University Health Sciences

Mitzi R. Krockover, M.D.Humana, Inc.

Manfred Kroger, Ph.D.Pennsylvania State University

Laurence J. Kulp, Ph.D.University of Washington

Sandford F. Kuvin, M.D.University of Miami

Carolyn J. Lackey, Ph.D., R.D.North Carolina State University

Pagona Lagiou, M.D., DrMedSciUniversity of Athens Medical School

J. Clayburn LaForce, Ph.D.

University of California, Los Angeles

James C. Lamb, IV, Ph.D., J.D.Blasland, Bouck & Lee

Lawrence E. Lamb, M.D.San Antonio, TX

William E. M. Lands, Ph.D.College Park, MD

Lillian Langseth, Dr.P.H.Lyda Associates, Inc.

Brian A. Larkins, Ph.D.University of Arizona

Larry Laudan, Ph.D.National Autonomous University of Mexico

Tom B. Leamon, Ph.D.

Liberty Mutual Insurance CompanyJay H. Lehr, Ph.D.Environmental Education Enterprises, Inc.

Brian C. Lentle, M.D., FRCPC, DMRDUniversity of British Columbia

Floy Lilley, J.D.Amelia Island, FlF

Paul J. Lioy, Ph.D.UMDNJ-Robert Wood Johnson Medical

School

William M. London, Ed.D., M.P.H.Walden University

Frank C. Lu, M.D., B CFEMiami, FL

William M. Lunch, Ph.D.Oregon State University

Daryl Lund, Ph.D.University of Wisconsin

George D. Lundberg, M.D.Medscape

Howard D. Maccabee, Ph.D., M.D.Radiation Oncology Center

Janet E. Macheledt, M.D., M.S., M.P.H.Houston, TX

Roger P. Maickel, Ph.D.Purdue University

Henry G. Manne, J.S.D.George Mason University Law School

Karl Maramorosch, Ph.D.Rutgers University, Cook College

Judith A. Marlett, Ph.D., R.D.University of Wisconsin, Madison

James R. Marshall, Ph.D.Roswell Park Cancer Institute

Margaret N. Maxey, Ph.D.University of Texas at Austin

Mary H. McGrath, M.D., M.P.H.Loyola University Medical Center

Alan G. McHughen, D.Phil.University of California, Riverside

James D. McKean, D.V.M., J.D.Iowa State University

John J. McKetta, Ph.D.University of Texas at Austin

Donald J. McNamara, Ph.D.Egg Nutrition Center

Michael H. Merson, M.D.Yale University School of Medicine

Patrick J. Michaels, Ph.D.University of Virginia

Thomas H. Milby, M.D., M.P.H.Walnut Creek, CA

Joseph M. Miller, M.D., M.P.H.University of New Hampshire

William J. Mill er, Ph.D.University of Georgia

Dade W. Moeller, Ph.D.Harvard University

Grace P. Monaco, J.D.Medical Care Management Corp.

Brian E. Mondell, M.D.Baltimore Headache Institute

Eric W. Mood, LL.D., M.P.H.Yale University School of Medicine

John W. Morgan, Dr.P.H.California Cancer Registry

W. K. C. Morgan, M.D.University of Western Ontario

Stephen J. Moss, D.D.S., M.S.Health Education Enterprises, Inc.

Brooke T. Mossman, Ph.D.University of Vermont College of Medicine

Allison A. Muller, Pharm.DThe Childrens Hospital of Philadelphia

Ian C. Munro, F.A.T.S., Ph.D., FRCPathCantox Health Sciences International

Kevin B. MurphyMerrill Lynch, Pierce, Fenner & Smith

Harris M. Nagler, M.D.

Beth Israel Medical CenterDaniel J. Ncayiyana, M.D.University of Cape Town

Philip E. Nelson, Ph.D.Purdue University

Malden C. Nesheim, Ph.D.Cornell University

Joyce A. Nettleton, D.Sc., R.D.Aurora, Co

John S. Neuberger, Dr.P.H.University of Kansas School of Medicine

Gordon W. Newell, Ph.D., M.S.,F.-A.T.S.Palo Alto, CA

Thomas J. Nicholson, Ph.D., M.P.H.Western Kentucky University

Steven P. Novella, M.D.Yale University School of Medicine

James L. Oblinger, Ph.D.North Carolina State University

Deborah L. OConnor, Ph.D.University of Toronto/The Hospital for

Sick Children

John Patrick OGrady, M.D.Tufts University School of Medicine

James E. Oldfield, Ph.D.Oregon State University

Stanley T. Omaye, Ph.D., F.-A.T.S.,F.ACN, C.N.S.University of Nevada, Reno

Michael T. Osterholm, Ph.D., M.P.H.University of Minnesota

M. Alice Ottoboni, Ph.D.Sparks, NV

Michael W. Pariza, Ph.D.University of Wisconsin, Madison

Stuart Patton, Ph.D.University of California, San Diego

James Marc Perrin, M.D.Mass General Hospital for Children

Timothy Dukes Phillips, Ph.D.Texas A&M University

Mary Frances Picciano, Ph.D.National Institutes of Health

David R. Pike, Ph.D.

University of Illinois, Urbana-ChampaignThomas T. Poleman, Ph.D.Cornell University

Charles Poole, M.P.H., Sc.DUniversity of North Carolina School ofPublic Health

Gary P. Posner, M.D.Tampa, FL

John J. Powers, Ph.D.University of Georgia

William D. Powrie, Ph.D.University of British Columbia

C.S. Prakash, Ph.D.Tuskegee University

Kary D. PrestenU.S. Trust Co.

Marvin P. Pritts, Ph.D.Cornell University

Daniel J. Raiten, Ph.D.National Institute of Health

David W. Ramey, D.V.M.Ramey Equine Group

R.T. Ravenholt, M.D., M.P.H.Population Health Imperatives

Russel J. Reiter, Ph.D.University of Texas, San Antonio

William O. Robertson, M.D.University of Washington School of Medicine

J. D. Robinson, M.D.Georgetown University School of Medicine

Bill D. Roebuck, Ph.D., D.A.B.T.Dartmouth Medical School

David B. Roll, Ph.D.University of Utah

Dale R. Romsos, Ph.D.

Michigan State UniversityJoseph D. Rosen, Ph.D.Cook College, Rutgers University

Steven T. Rosen, M.D.Northwestern University Medical School

Kenneth J. Rothman, Dr.P.H.Boston University

Stanley Rothman, Ph.D.Smith College

Edward C. A. Runge, Ph.D.Texas A&M University

Stephen H. Safe, D.Phil.Texas A&M University

Wallace I. Sampson, M.D.Stanford University School of Medicine

Harold H. Sandstead, M.D.University of Texas Medical Branch

Charles R. Santerre, Ph.D.Purdue University

Herbert P. Sarett, Ph.D.Sarasota, FL

Sally L. Satel, M.D.

American Enterprise InstituteLowell D. Satterlee, Ph.D.Oklahoma State University

Jeffrey Wyatt SavellTexas A&M University

Marvin J. Schissel, D.D.S.Roslyn Heights, NY

Lawrence J. Schneiderman, M.D.University of California, San Diego

Edgar J. Schoen, M.D.Kaiser Permanente Medical Center

David Schottenfeld, M.D., M.Sc.University of Michigan

Joel M. Schwartz, M.S.Reason Public Policy Institute

David E. Seidemann, Ph.D.Brooklyn College/Yale University

Patrick J. Shea, Ph.D.University of Nebraska, Lincoln

Michael B. Shermer, Ph.D.Skeptic Magazine

Sidney Shindell, M.D., LL.B.

Medical College of Wisconsin

Sarah Short, Ph.D., Ed.D., R.D.Syracuse University

A. J. Siedler, Ph.D.University of Illinois, Urbana-Champaign

Lee M. Silver, Ph.D.Princeton University

Michael S. Simon, M.D., M.P.H.Wayne State University

S. Fred Singer, Ph.D.Science & Environmental Policy Project

Robert B. Sklaroff, M.D.Elkins Park, PA

Anne M. Smith, Ph.D., R.D., L.D.The Ohio State University

Gary C. Smith, Ph.D.Colorado State University

John N. Sofos, Ph.D.Colorado State University

Roy F. Spalding, Ph.D.University of Nebraska, Lincoln

Leonard T. Sperry, M.D., Ph.D.Barry University

Robert A. Squire, D.V.M., Ph.D.Johns Hopkins University

Ronald T. Stanko, M.D.University of Pittsburgh Medical Center

James H. Steele, D.V.M., M.P.H.University of Texas, Houston

Robert D. Steele, Ph.D.Pennsylvania State University

Judith S. Stern, Sc.D., R.D.University of California, Davis

Ronald D. Stewart, O.C., M.D., F RCPCDalhousie University

Martha Barnes Stone, Ph.D.

Colorado State UniversityJon A. Story, Ph.D.Purdue University

Michael M. Sveda, Ph.D.Gaithersburg, MD

Glenn Swogger, Jr., M.D.Topeka, KS

Sita R. Tatini, Ph.D.University of Minnesota

Steve L. Taylor, Ph.D.University of Nebraska, Lincoln

James W. Tillotson, Ph.D., M.B.A.Tufts University

Dimitrios Trichopoulos, M.D.Harvard School of Public Health

Murray M. Tuckerman, Ph.D.Winchendon, MA

Robert P. Upchurch, Ph.D.University of Arizona

Mark J. Utell, M.D.University of Rochester Medical Center

Shashi B. Verma, Ph.D.

University of Nebraska, LincolnWillard J. Visek, M.D., Ph.D.University of Illinois College of Medicine

Donald M. Watkin, M.D., M.P.H., F.A.C.P.George Washington University

Miles Weinberger, M.D.University of Iowa Hospitals and Clinics

Lynn Waishwell, Ph.D., CHESUniversity of Medicine and Dentistry ofNew Jersey

Janet S. Weiss, M.D.University of California at San-Francisco

Simon Wessley, M.D., FRCPKings College London and Institute of

Psychiatry

Steven D. Wexner, M.D.Cleveland Clinic Florida

Joel Elliot White, M.D., F.A.C.R.John Muir Comprehensive Cancer Center

Carol Whitlock, Ph.D., R.D.Rochester Institute of Technology

Christopher F. Wilkinson, Ph.D.

Burke, VAMark L. Willenbring, M.D.Veterans Affairs Medical Center

Carl K. Winter, Ph.D.University of California, Davis

Lloyd D. Witter, Ph.D.University of Illinois, Urbana-Champaign

James J. Worman, Ph.D.Rochester Institute of Technology

Russell S. Worrall, O.D.University of California, Berkeley

Panayiotis M. Zavos, Ph.D., Ed.S.University of Kentucky

Steven H. Zeisel, M.D., Ph.D.The University of North Carolina

Michael B. Zemel, Ph.D.Nutrition Institute, University of Tennessee

Ekhard E. Ziegler, M.D.University of Iowa

A C S H B O A R D O F S C I EN T I F I C A N D P O L I C Y A D V I S O R S

The opinions expressed in ACSH publications do not necessarily represent the views of all ACSH Directors and Advisors.

ACSH Directors and Advisors serve without compensation.


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vaccinations: what parents need to know

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