All shot up: the flu vaccine controversy

All shot up: the flu vaccine controversy

The hot topic right now is what to do about childhood vaccination against epidemic influenza, following the series of apparent adverse reaction to influenza vaccine in pre-schoolers. Already there has been a lot of heat, plenty of noise but not a lot of light on the issue. It is frustrating for all concerned. Not only for the parents of children who’ve had rash, fever or even a febrile convulsion. It is also frustrating for responsible health professionals who’ve advocated an expanded influenza vaccination programme on the basis of hard-won statistical evidence in order to reduce the risk of influenza complications in the most vulnerable. An early evaluation appeared to indicate that the H1N1/09 specific vaccine would be safe in children, though a more recent report indicated a higher rate of mild to moderate adverse reactions in children. Earlier this year there was an impression that there had been a disappointing uptake of pandemic flu vaccine after the winter epidemic of 2009. This was suprising given the severity of disease in specific adult groups, some of whom required admission to intensive care.

In the few days since this issue first arose a series of possible explanations have been offered for the series of apparent vaccine reactions in paediatric patients. These include an immune memory response in children who had already been exposed during last year’s flu season,  a particular batch of vaccine, vaccine potentiation by a second and possibly unrelated viral infection, an abnormally exaggerated vaccine response, or a combination of more than one of these.

Teasing out the various strands of possible cause and effect is a complicated process under the best of conditions. The nature of the public debate means that the health detective work that needs to proceed urgently and methodically risks being diverted by critics who hold to a more general anti-vaccine agenda. Expert opinion, given with the best of intentions is currently in danger of being used out of context to support an unscientific, 19th century view of vaccination.

Readers of this Blog are reminded that it takes a sizeable body of evidence to pin the blame on a specific microbe as both sufficient and necessary cause of a given disease outcome, even if the microbe has been administered deliberately by needle.

There are four key evidentiary stages to nailing the microbial culprit;

  1. congruence
  2. consistency
  3. cumulative dissonance
  4. curtailment

How these operate can be found in the original paper. In outline, the clinical and pathological features of individual cases, the epidemiology and the molecular biology must add up. But that just get’s you to first base. There must also be consistency, a mechanistic explanation for how the microbe exerts its effects, and finally a demonstration of the effect of one or more specific interventions to curtail the infective process.

Application of this evidence-building exercise to the current alleged vaccine reactions at the present time illustrates (a)  the strength of evidence for a causal relationship, and (b) helps identify priorities for further investigation, without losing sight of the need to continue vaccination of vulnerable adults in groups who have yet to show any adverse effects of the current influenza vaccine.

These comments are subject to the caveat at the bottom of the MicroGnome website’s homepage.

Mud and blood

CAPT JD Inglis, DSO, MC & bar. 1901-1975

Beneath Hill 60, for details click link below

While at high school, the μGnome spent cold autumn afternoons scrambling around in the mud on a rugby pitch. Every now and again we’d be send off by the busload to battle with other schools on their muddy pitches. One away match was particularly memorable. The year before that school had posted a monumental winning score by the simple method of putting one of their best sprinters out on the wing. Our job was to reduce their score by bringing the winger down before he reached the try line, and the best way to do that was with a classic rugby tackle. Not a good way to keep the rugby strip clean. Time and again we put ourselves in the line of fire, throwing bony adolescent shoulders at shins and burying our faces in the increasingly slimy mud. We didn’t win the match, but we cut the score against us to less than half the previous year’s. We felt like heroes.

War memorial

Outside the main school building was an impressive war memorial; a large bronze of a former pupil collapsing on a battlefield and shouting the one word ‘Onward!’ with his dying breath. As pupils from another school, we were told the cautionary and probably apocryphal tale of an ill-advised student who’d been expelled for putting a peeled orange in the upturned hand of the bronze FP. The sacrifices made by that generation are not a joking matter, and it is a sobering thought that the same college describes its school colours as ‘mud and blood’.

Messines Ridge

The mud and blood of the Western Front have been superbly depicted in Jeremy Sims recent movie, Beneath Hill 60. This feature length film is a powerful visual essay on the futility of industrial-scale trench warfare. It tells the story of the 1st Australian Tunnelers; a unit formed to excavate underneath the enemy lines. The film has a narrative integrity that leaves few if any hostages to the crass jingoism of that age, and yet it successfully portrays how individuals got swept up by the tide of events and sucked into their grip. This is a movie about heroes. It says most about the small acts of heroism that maybe don’t even rate a mention in despatches. It also throws open a window on the consequences of decisions that individual soldiers have to make in the heat of battle.

Infection in the trenches

There is another encounter with battlefield mud that gets little mention in Beneath Hill 60; the infections troops suffered as a result of trench warfare. There were infections other than influenza (whose effect was so great the 1918-19 pandemic may have alterered the course of the final stages of WW1) that commonly befell the men who huddled in trenches against shell and machine gun fire. These included trench fever, a louse-borne disease caused by Bartonella quintana; Leptospirosis and gas gangrene. Interestingly, the tropical soil-borne disease known as melioidosis is endemic in the area around Townsville, where filming was done for Beneath Hill 60. In fact, the 6th World Melioidosis Congress will be held there later this year. The μGnome wonders whether any of the actors have been exposed to Burkholderia pseudomallei, the bacteria that cause melioidosis, as a result of encounters with mud and blood on the film set in North Queensland.

ANZAC memorial

Today, April 25th, is ANZAC Day in Australia and New Zealand; the 95th anniversary of the fateful Gallipoli landings. Tragic failure though the landings proved to be, this day is now an opportunity to remember those in the armed services of both countries who held the door shut against the enemy outside. It is a day to remember those who have given much, sometimes all, in the service of others, including those who continue to put their personal safety on the line to preserve the life most of us enjoy in peace, quiet and relative obscurity. Some are critical of the semi-religious tone to this time of reflection and memory, but as Stephen Ambrose documented in his account of one US soldier’s experience during the fierce fighting at Bastogne during 1944, “there are few atheists in foxholes”. Extreme challenges make us all dig deep, and not just to the bottom of the foxhole.

Marking their legacy

For those who want to do something practical as a mark of remembrance, you can make a donation to Legacy who provide support to the families of former diggers. And for those who specifically want to direct their generosity overseas, Australian communities are twinning with towns and villages in East Timor to assist their development and reconstruction. This ANZAC Day, the ABC will run a documentary on the support East Timor gave Australians during World War 2; reason enough to repay that generosity through the appeals Australian communities are now running.

Family ties

Today is also the day many remember overseas friends and relatives who were caught up in both world wars and smaller conflicts. In my own family, parental and grandparental generations fought in Europe. Those from my grandfather’s generation who survived the rigors of trench warfare during the First World War, were pressed into service at the start of the Second World War. Having survived his first two weeks as a subaltern, raids into no-mans-land, poison gas and a plane crash during WW1, he joined up in 1938 and stayed behind in northern France with elements of the 51st Highland Division as part of the rearguard action that continued until their final surrender at St Valery (after the Dunkirk evacuation). The action near Escarbotin lasted little more than three days and was an increasingly desperate affair with an inevitable conclusion. He spent the remainder of WW2 in POW camp. Decorations for distinguished service seem a small token of gratitude for a gritty determination not to cave in to pressure from a much stronger enemy. But aside from military calculations of risk, benefit, gain and loss is the human dimension of extreme conditions in which deep friendships are forged, even if life-long turns out to be a matter of hours or days. Grandfather noted in his first footnote to the submission for the official regimental history that “the action was conducted without the pipes” [bagpipes]. It’s a matter of perspective. Beneath Hill 60 captures those moments of jocular, men-in-a-trench humour rather well.

CAPT JD Inglis, DSO, MC & Bar (1901-1975)