Thursday 28 November 2013

Drugs are not safe... but they can save your life.

I recently participated in a little vaccination debate on Facebook, triggered by some negative press about Gardisil, the 'cervical cancer' vaccine (this is worth reading if you are concerned). It quickly became a discussion about immunisation in general. One of my highly educated and very respected friends highlighted the difficulties he faced when trying to make an informed decision about what was best for his child. It seems that it is such a sensitive issue that people on both sides of the debate can quickly become overly emotional and unable to provide clear, unbiased information. I weighed in and just found myself repeating 'risk vs benefit'. For me this is what all decisions basically boil down to. I feel like this concept is not considered often enough in the prescribing and taking of drugs.

We don't call them drugs though, we call them medicines. Only the scary illegal ones are drugs right? It's all sugar-coating- a medicine is a drug, a lot of the natural things we take are technically drugs. The definition of a drug is: a medicine or other substance which has a physiological effect when ingested or otherwise introduced into the body (Oxford Dictionary). So food is a drug too. I'm going to confine my rant to legal pharmaceutical drugs here though.

 Humans are complicated creatures and most of  medicine is trial and error. The good news is that the trial part starts a long time before we have access to anything. If you are prescribed or recommended a drug by a health professional it is because we have a really good idea of how it is going to work in your body and also any potential problems it can cause. In fact most adverse reactions only become a problem because people don't report them. When I am working as a Pharmacist, I consider that my most important role is to educate people about what they are taking, what to look for and what and when to report. Sadly, there are more and more people choosing not to allow time to speak to the Pharmacist during their visit to the Pharmacy and prefer to 'Google it". Dr Google is much cooler than I am and is available at 3am to freak you out. 

I get really frustrated when somebody presents a new script and utters the phrase "There aren't any side effects with this are there?"  If I printed out a Consumer Medication Information (CMI) leaflet for paracetamol there would be people too scared to take it and yet it is one of the drugs people casually (mildly) overdose on all the time. How many times have you heard someone say "I was taking four paracetamol at a time to deal with the pain"?  I hear it all the time, often in social settings where it isn't appropriate to intervene. For completeness, the maximum dose of paracetamol in a 24 hour period is 4 grams or 8 standard tablets- beyond that you risk liver damage.

Everything has side effects, a lot of them are minor and resolve by themselves but the only way to avoid a side effect is not to take a drug. Sometimes you have to. If you have high cholesterol, a family history of heart disease and you have already modified your diet to reduce saturated fat, increased your exercise and your cholesterol profile hasn't improved; then a medication to control your cholesterol and stabilise the plaque in your arteries may save your life. If you think it is easier just to take the tablet so you can still eat fried food and cake then you are exposing yourself to unnecessary risks.

I think this is the crux of the immunisation debate. When we vaccinate we are introducing a substance to a healthy person to stop them from getting sick in the future- they aren't sick now and so potential side effects seem much more risky.. When people are sick they are pretty much prepared to do/take anything to get better. The obvious example is cancer- we use cytotoxic drugs. Cyto, meaning cells and toxic, meaning poisonous. Side effects? Heck yes! Yet it rarely takes much convincing to put people on a chemo regimen because the potential benefit ie. living, outweighs the risks. 

In developed countries we are fortunate to have the decision to vaccinate. It is not compulsory and it can feel unnecessary  because a history of vaccination has almost removed these diseases from our consciousness. Measles cases are so rare they make national news; diptheria and polio are virtually unheard of and tetanus is only if you step on a rusty nail right? The fact that most people couldn't tell you what Hib is (Haemophilus influenzae type B- can cause meningitis in children) or how Rotavirus affects you (vomiting, diarrhoea, dehydration) is just awesome. If the numbers of people choosing not to vaccinate continue to rise, there is a risk that we will start to see serious cases of these diseases again. Whooping cough is one terrifying example, waning immunity in adults and older children (the current vaccine does not provide lifetime immunity) means that the disease can flourish, particularly in populations with lower rates of vaccination. It is highly contagious and reaches epidemic proportions every 3-4 years. Eight babies in Australia have died from whooping cough since 2008 and many more affected children will have ongoing respiratory problems (good article about whooping cough here). It is easy to understand why people are fearful of vaccination- a serious adverse effect, if it occurs, can be life-changing- but so can a case of whooping cough or measles. There are no easy answers but at the end of the day you need to weigh up the risks vs the benefits.

When thinking about vaccination or just medicine in general I think we need to be as objective as possible and consider the following:

Do your research through reputable sources. Talk to your Doctor/Pharmacist/Nurse or all three and if you don't get a helpful open-minded response from one then seek another opinion. Three to six years of tertiary education plus multiple years of post-graduate training and experience outweigh three hours of largely uneducated opinion on Dr Google. Every time.

When you start a new medication be informed of the side effects and aware of what and when to report and how urgently. In the case of vaccination I fully believe in staying close by the clinic or at the clinic for a while so that if something goes horribly wrong you can seek medical attention quickly. Similarly I would stay home with a child that had been vaccinated for the remainder of the day to observe for any side effects. I do that with my dog.

Don't be afraid to ask for options. Before starting a new medication discuss the possibility of life-style modification or other non-pharmacological intervention. In the case of vaccines, it may be appropriate to choose, in consultation with your doctor, to vaccinate for the diseases with higher rates of complications. 

Look at the statistics objectively. Allergic reaction to Infarix hexa which vaccinates for Diptheria, Tetanus, Pertussis, Hib, Polio and Hepatitis B, occurs in less than 1 child in 1 million (taken from here). Whereas diptheria is fatal in up to 20% of children under 5; Tetanus has a mortality rate estimated at around 11% and can be contracted from mild puncture wounds or even just a deep scratch if the bacteria is present in the environment.

If you decide not to take a prescribed medication as an adult then that is your choice and you live with your decision. If you decide not to vaccinate your child then they need  to live with your decision. You will need to have a conversation with your child about immunisation when he/she is old enough to make his/her own decisions (children's wishes about medical treatment need to be considered from about 12 years of age and at 16 they are the legal age of consent under most state laws). This is especially important as they enter the age where the potential for risk-taking and travel and therefore potential exposure increases. Also, there are  some diseases, for example measles and chicken pox,  that can be more severe in adults. 

If you or your child are not vaccinated, be prepared to act quickly. If  you have had contact with someone that becomes sick from a vaccinable disease, seek medical attention immediately. In most cases post-exposure prophylaxis can either prevent or reduce severity of the illness.

I personally am pro-vaccination but I completely respect those who aren't. Whatever you decide to do medically, the bottom line is that you need to be educated about the risks and the benefits of your decision and act accordingly.

Please note: This is just my opinion, albeit an informed one, inspired by a Facebook rant and fueled by years of helplessly watching people be complacent with their health. Please do your own research and consult a health professional in regards to any medical matters.

5 comments:

  1. Great post!

    As a former registered nurse, I'm very much pro vaccination and don't understand why people wouldn't take advantage of a medication which prevents a serious or fatal illness, especially when the benefits far outweigh the risks.

    I mean Gardisil not only offers decent protection to women from cervical cancer but also takes a lot of pressure off the health system in terms of unnecessary procedures and treatment which are given to women when they have an abnormal Pap smear. Why wouldn't you want your daughter to have this?!

    I'm not as kind as you when it comes to this subject; I don't understand the anti-vaccine movement at all.

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  2. Most people I know dont vaccinate. I respect their choice as they went and did the research before coming to a decision. However when one of the people who had whooping cough was holding my brand new baby I put my foot down. Keep your diseases to yourself!

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  3. This is a great post Nicole. I am also, now, pro-vaccine, but I think there has to be room for questioning received wisdom, and this was the struggle we found when we were thinking about our (at the time) as-yet unborn child. We had a number of people around us pushing anti-vaccine propaganda at us, but even I could tell that the science was very shonky. But there were some questions we had, and we found it very very difficult to find balanced literature, it was either flaky bad science scaremongering, or it was "do what we say we know best how dare you ask just do this" equally poorly reasoned propaganda from the health system. Nobody was actually engaging with the often reasonable questions people may have.
    Eventually we found William Sears' "The Vaccine Book" which treated questioning parents with respect. Sears points out that there _may_ be some concerns with mixed vaccines, and also with the number of vaccines given in a short space of time. Sears recommended that _if_ parents had a concern, they could ask for the vaccines to be separated or spread out, with no compromise to invididual or herd immunity. But when we approached our GP with these ideas, we were basically howled out.
    Our GP asked me what I knew about statistics and basically belittled my education. As someone with a PhD in linguistics, I know I have a hell of a lot more understanding of scientific method and statistics than a GP with an MD. But it wasn't even this, it was the hysteria with which we were met for even daring to ASK.
    The clinic's health nurse actually accused me of neglect when I said we weren't going to vaccinate for Hep B, since we knew neither of us had it and there was no known mechanism by which our baby or infant was going to be exposed to it. This nurse told us that the Hep B virus can live outside the body for up to 48 hours and there were known cases of people contracting it from touching a doorknob. This is utter rubbish.
    One of the things Sears suggests is separating the measles, mumps and rubella vaccines, rather than going for the combined MMR as some of the concerns with the MMR that was floating around a few years ago were not entirely disproven. However, in Australia this is not possible (it is in the USA, where Sears published his book).
    Another point that Sears makes is that some people have a quite reasonable concern about mercury, and there is in fact no established safe level for mercury. He suggests, again _if_ parents are concerned about this, spacing out the mercury-copntaining vaccines over more time will minimise the chances of mercury toxicity.
    This again does not compromise individual or herd immunity.
    (to be continued)

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  4. (continuation)
    Eventually we established a schedule that would see our child receive all the vaccines (Except two, see below) but with an overall extension to the schedule of about a year, spacing them out. We elected NOT to vaccinate for Hep B or for Chicken Pox. Our child got whooping cough despite being vaccinated for it (fully).
    Dialogue is important. Both sides of this debate seem to have their wagons in a circle and are resulting to untruth to promote their view, or rather scare people into it.
    I do think vaccination is important, for most of the diseases on the schedule. And perhaps unlike Nicole, I actually think it matters that all kids get these vaccines unless a pre-existing medical condition or genetic predisposition makes it likely to be unsafe for that kid. Because of the importance of herd immunity. This is a matter of public health, not just individual health. Just like we don't allow some people to drive drunk, even though they think they are perfectly capable, the well-being of the whole must be considered when setting limits on individual liberty.
    Tim Minchin said something funny but to the point - when he described Byron Bay as a place where you could listen to good blues, but you have to get your palm read, and maybe get measles in the process (http://www.smh.com.au/comment/science-inspires-so-dont-let-your-art-rule-your-head-20131101-2wrjb.html).
    Lovely thought-provoking stuff, Nicole.

    Eventually we established a schedule that would see our child receive all the vaccines (Except two, see below) but with an overall extension to the schedule of about a year, spacing them out. We elected NOT to vaccinate for Hep B or for Chicken Pox. Our child got whooping cough despite being vaccinated for it (fully).
    Dialogue is important. Both sides of this debate seem to have their wagons in a circle and are resulting to untruth to promote their view, or rather scare people into it.
    I do think vaccination is important, for most of the diseases on the schedule. And perhaps unlike Nicole, I actually think it matters that all kids get these vaccines unless a pre-existing medical condition or genetic predisposition makes it likely to be unsafe for that kid. Because of the importance of herd immunity. This is a matter of public health, not just individual health. Just like we don't allow some people to drive drunk, even though they think they are perfectly capable, the well-being of the whole must be considered when setting limits on individual liberty.
    Tim Minchin said something funny but to the point - when he described Byron Bay as a place where you could listen to good blues, but you have to get your palm read, and maybe get measles in the process (http://www.smh.com.au/comment/science-inspires-so-dont-let-your-art-rule-your-head-20131101-2wrjb.html).
    Lovely thought-provoking stuff, Nicole.

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  5. Excellent post, Nicole, and Rob, great analogy about drunk drivers.

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