Wrinkles in the Force

Larry I. Lutwick, MD, Norberto E. Soto, MD

Disclosures

April 26, 2002

Introduction

Snow drifted against the hospital buildings, carried by the chilly north wind. The Infectious Disease consult team, with Dr. Schmeckman at point position, had scored again, making a diagnosis of Charcot's intermittent fever in a 79-year-old woman with a history of paroxysmal rigors (see Schmeckman's Questions for the House Staff, Question 1). She was about to be scheduled for surgery to remove an inflamed gall bladder and its wandering stones, which were every so often obstructing the common bile duct. In the adjacent bed of the double room was a young woman with relapsing pancreatitis. She was entertaining herself by watching one of the myriad of TV talk shows. This particular visual tabloid was accusing the vaccine industry of a plot to cover up a world of alleged immunization disasters.

"Is there any truth to this stuff?" asked one of the medical students rotating through the ID service.

"Nothing done through the art of medicine is absolutely safe, a fact known to all scientists and physicians but not to judges, trial lawyers, or juries," answered the crusty, law-weary professor. "It is all a risk/benefit analysis, a trade-off, where preventing the target disease outweighs any real or theoretical vaccine risks. While we're at it, what have we found out about this patient's current vaccination status?"

The medical resident, cognizant of Schmeckman's keen interest in up-to-date immunizations, reported that she had given the patient an adult diphtheria/tetanus toxoid booster (see Question 2). Furthermore, a polyvalent pneumococcal vaccine had been administered 2 years before, but no influenza vaccine had been given in several years.

"I got sick from it once," interjected the patient, who seemed quite grateful for the plans being made for her preventive maintenance.

"Allergic to eggs?" asked the attending, suspecting this to be the reason for the problem.

"Nope," continued the patient, "six years ago, my doctor gave me a flu shot and I got the stomach flu from it, and my husband got it from me." (See Question 3.) Schmeckman smiled as the consult team exited from the patient's room while, on the TV, a media reporter continued on about the hazards of vaccine use, but, true to form, did not mention the impressive plus side.

"Do you agree with what the patient claimed?" asked Dr. Thomas, one of the rotating medical residents.

"Another post hoc argument," answered Schmeckman. "Just because an episode of vomiting followed an influenza vaccination doesn't mean the two events are related." Schmeckman reminded the team that "post hoc, ergo propter hoc"--meaning that if one event follows another in time, the first event caused the second to occur--is not at all necessarily true. "Just because my daughter Jonina woke up with a sore throat doesn't mean that the pharyngitis was caused by her slumber," added the part-time philosopher.

"Besides," he continued, "not only can you not get influenza from the flu vaccine, because it is a killed product (see Question 4), but the stomach flu, as it is called by nonmedical people, has nothing to do with influenza. Rather, stomach flu is caused by a variety of other agents, including Norwalk virus. However, severe reactions related to immunization problems have occurred quite rarely, resulting in morbidity and mortality in the vaccinees."

Bridget Kildare, one of the medical students, broke in, "Can you tell us more about some of these vaccine fiascoes? Could the TV program have some basis in fact? I just read a novel about biological terrorism.[1] Could this actually happen from drugs or vaccines?"

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