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Too many vaccines, too quickly?

Air Force Times
By Deborah Funk

Concurrent inoculations increase your risk of getting sick, some say. Now, scientists are taking a look

Army Spc. Tyran Duncan no longer needs a machine to draw breath, but his hands can’t grip tightly and he wears braces on his legs to help him walk.

Duncan, 20, who was temporarily medically retired Nov. 24, hasn’t completely recovered from the Guillain-Barré syndrome that struck him two years ago, a few weeks after he received numerous military-related vaccinations.

But at least he’s not completely paralyzed anymore.

He believes the vaccinations caused his health problems, but since he received multiple shots, one after another, he has no idea which vaccine or vaccines may be to blame. He hasn’t received any vaccinations since and may not ever again — not even for the flu or for trips abroad.

“He wouldn’t know which shots not to have,” said his grandmother, Faye Harville, who shares her home in Tennessee with Duncan. “He couldn’t pursue a life where he might be able to travel with a job.”

A long military tradition

From the ragtag Continental Army that fought for George Washington to the dust-covered grunts in Iraq and Afghanistan today, American troops have been given vaccines to protect them against diseases their leaders say threaten their health and the military’s readiness.

In the Revolutionary War, troops were inoculated with live smallpox. After the Spanish-American War, typhoid vaccine was introduced. By World War II, U.S. troops got multiple jabs, often at the same time, a practice that continues today.

Medical experts say numerous simultaneous shots generally are safe, and studies in young children who get multiple shots have not proved otherwise.

“You are bombarded with far more ... immunologic challenges in your environment than you’d ever encounter from a vaccine,” said immunology expert Dr. Paul Offit of The Children’s Hospital in Philadelphia. “If you really want to get scared, just take a nasal swab. … It’s teeming with bacteria, and you’re making an immune response.”

Available data also show no patterns of long-lasting bad side effects in adults who get two or more shots together, but such studies are more limited than those in childhood populations and derived largely from military practice and civilian travel medicine clinics.

Still, “This is a long-standing practice,” Dr. Stephen Ostroff, president of the Armed Forces Epidemiological Board, said of multiple simultaneous vaccinations. “There is virtually no data to say there is a problem with this.”
“You conclude that at least there is no evidence that it is detrimental,” added retired Army Lt. Gen. Ronald Blanck, who was the Army surgeon general when the Pentagon announced in 1997 it would vaccinate all U.S. service members against anthrax — a program that was halted in late October after a federal judge ruled it illegal.

But while most experts say numerous vaccinations on the same day is safe, the military acknowledges that it is partnering with the Centers for Disease Control and Prevention to more closely study whether vaccines are linked to illnesses and, if so, in what combinations and in which people.

Lethal side effects

Vaccines, like any drug, can trigger bad reactions. So when someone receives more than one vaccination and suffers a side effect, finding answers can be difficult.
Bawana Perry believes a combination of vaccines played a role in the death of her sister.

Pfc. Arwana Lattimore-Oliver joined the Army Reserve in 1991, re-enlisted and was serving at Fort Riley, Kan., in March 1998. In April 1998, she got at least three shots, for yellow fever, typhoid, and diphtheria and tetanus, on the same day. Later that month, she got a hepatitis shot.

In September, she went to the hospital with vomiting and low heart rate, according to a source familiar with her medical records.

Her condition worsened over the following months, robbing her of her vision and sense of touch, her balance, and ability to walk or even feed herself. She also contracted multiple sclerosis and slowly faded away until she died May 24, 2002, at 28.

“She went from one of the healthiest people you could know to just dwindling down until she was gone,” said Perry, of Tallahassee, Fla.

After her discharge from the military, Oliver moved near her family in Tallahassee, Fla. Civilian doctors who treated her there and investigated her multiple sclerosis questioned whether she received any vaccinations in the military prior to falling ill, but they could not say what role vaccines may have played in her disease, Oliver’s sister said.

Moses Lacy of Lynwood, Ill., had a similar experience with his daughter, Army Spc. Rachel Lacy, more than a year ago.

Prior to deploying to the Persian Gulf in March 2003, she received these shots in a single day: anthrax, smallpox, hepatitis B, typhoid VI, and measles, mumps and rubella — and died just 33 days later. She was 22 years old.

Two expert panels — one affiliated with the CDC, the other under the Department of Health and Human Services — said one or more of the vaccines may have triggered an undiagnosed autoimmune disorder that killed her. But they could not pinpoint which ones. Her case was the only one of four cases of severe illness or death reviewed by the panel that found a link between vaccination and death.

The coroner said in his official report that smallpox and anthrax vaccines may have contributed to Lacy’s death.

Her father agrees, dismissing the theory that she had an underlying autoimmune disease. He questions giving numerous shots on the same day, saying it can only complicate learning which vaccine caused a problem.

“How do you know? Was it one specific, or the combination of them all?” Lacy said.
Army Col. John Grabenstein, deputy clinical director of the Military Vaccine Agency, acknowledges that “it’s difficult to tease them out.”

“One of the first things you do is look for the usual suspects,” Grabenstein said. “What has vaccine ‘Q’ been shown to cause before?”

But even that doesn’t always yield answers.

New look at immune responses

The human immune system is capable of handling more than one immune stimulus at a time. Young children trade viruses, as do military recruits in barracks and travelers on crowded planes.

One streptococcus vaccine has 23 types of strep. The tetanus shot combines tetanus and diphtheria. One multiple vaccine expert says the human immune system could handle up to 10,000 vaccine ingredients at a time that cause an immune response, or “more [shots] than someone would sit still for,” Grabenstein said.

“What’s the maximum amount that’s safe?” he said. “We don’t know that there is a maximum.”

To find an answer, defense officials plan to study the safety of dispensing multiple vaccines on a single day. “Because we have a very well-monitored population for whom we know who gets sick how often, we have an opportunity to inform the general public,” Grabenstein said.

A newly formed Vaccine Analytic Unit will study whether vaccines are linked to illness and, if so, in what combinations and in which people. Most of the work will focus on anthrax vaccine, but it also will explore the issue of near or concurrent vaccinations.

The VAU, a joint effort of the Pentagon and CDC, will mine the military’s data to find common combinations of simultaneously administered vaccines and whether certain ones may be linked to more or worse side effects than others.

“No one really knows if there is something to be further investigated yet,” said Daniel Payne, a CDC epidemiologist and the unit project officer.

The work will begin early next year, and experts are developing methods to try to differentiate which vaccine might be involved in the case of adverse events.
“If we do find an association, we hope to narrow it down a little bit more,” Payne said.

Waiting in limbo

Duncan believes a vaccine sparked his Guillain-Barré syndrome, but he has no idea which one. Medical experts in Tennessee can’t say for sure that the vaccines injured him, said Harville, his grandmother.

“Nobody really says what caused it,” she said.

But when doctors first examined him after he fell ill, Duncan recalls seeing an Army hospital document that said his condition could be related to vaccination, he said.
As a new recruit, Duncan got four shots on a single day in August 2002. Later that month, he said he got more, but there is no record of at least two shots he had been told he was receiving, for anthrax and flu. Harville said the Army claims he didn’t get those vaccinations, and anthrax vaccine is not included in a Defense Department list of required shots for new recruits. Within a couple of weeks, Duncan began losing control of his limbs. His drill sergeant thought he was faking; Duncan himself thought he was just fatigued. But then two soldiers had to carry him to sick call, and he couldn’t feel his foot when the doctor poked it with a needle. Diagnosed with Guillain-Barré, he was paralyzed for 11 months, spending three of them on a ventilator.

“I’d been getting real draggy. I couldn’t pick up my feet, hold a glass to take a drink,” Duncan said. “Once I started noticing, it took two days and I was completely paralyzed.”

Guillain-Barré syndrome is a rare disorder in which the body’s immune system damages the peripheral nervous system outside the brain and spinal cord. It usually appears after a gastrointestinal or respiratory infection, although it can also follow vaccination or surgery.

It was definitively linked to the 1976 swine flu vaccine. Once since then, in the 1990s, a slight increase in Guillain-Barré was reported after influenza vaccination, but some experts still dispute that. There are also reports of it following anthrax vaccination in service members, but defense officials say the rate in that group was the same as for the general population.

Its onset is also reported following the use of other drugs, said a top Army immunologist.

The cause of Guillain-Barré, which affects one or two people in every 100,000, is unknown, but most victims recover.

“It’s very hard to study because it’s so rare,” said Army Col. (Dr.) Renata Engler, an immunology expert at Walter Reed Army Medical Center in Washington and director of the Vaccine Healthcare Centers Network.

The network, launched at Walter Reed in 2001 and since expanded to three other sites, helps treat patients who have fallen ill with various ailments after vaccination and finds ways to reduce unwanted side effects. Through detailed record keeping and reporting, it also can pinpoint rare adverse reactions to particular vaccines.

Hands-on medicine, where detailed histories are taken and patients are treated, can yield new data, including identifying health problems that may be linked to vaccination.

But that won’t help people such as Duncan, who says his military medical history is incomplete. He can’t supply his full vaccination records because he said the Army has provided only part of his shot records from boot camp. “They claim they can’t find them,” he said.

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