Vaccine court's ruling adds to confusion over autism link

Washington -- Physicians are being called upon, once again, to address concerns about the safety of childhood vaccines. This time families' queries are driven by a special vaccine court's decision to pay for the care of a young girl injured by vaccines.

The court ruled last fall that 9-year-old Hannah Poling's underlying mitochondrial disorder was aggravated by the shots which she received as a toddler and resulted in brain dysfunction and "features of autism spectrum disorder."

News of the ruling made waves after it was recently leaked to the public.

The case, however, does not have broad application, and families can be reassured that having their children vaccinated is still the safer approach, experts said.

The mention of autism caught the attention of some who have long suspected that vaccines trigger the condition. However, a preponderance of scientific evidence gathered by Centers for Disease Control and Prevention studies and Institute of Medicine reports has cleared vaccines and the mercury-containing vaccine preservative thimerosal of autism involvement. Regardless, many parents and others remain unconvinced.

The advice for physicians in light of the new case is to "know what this set of events says and doesn't say," said Louis Z. Cooper, MD, a member of the National Network for Immunization Information's steering committee. NNii, a group to which the AMA belongs, provides science-based vaccine information.

"The bottom line is that the court decision is not germane to any but a very few American children. The best summary is, there are a few unanswered questions but this doesn't change the need to vaccinate," added Dr. Cooper, also a past present of the American Academy of Pediatrics.

A major reason that question marks regarding the case remain is that the judgment remains sealed, and federal health officials are still not able to explain it fully.

But in a press briefing about the general issues surrounding it, CDC Director Julie L. Gerberding, MD, MPH, said, "Let me be very clear that the government has made absolutely no statement about indicating that vaccines are a cause of autism. That is a complete mischaracterization of the findings of the case and a complete mischaracterization of any of the science we have at our disposal today."

A rare disorder

The ruling also put a spotlight on mitochondrial diseases. About one in 4,000 children in the United States will develop mitochondrial disease by the age of 10, and 1,000 to 4,000 children each year are born with some type of the disease, which can affect cells of the brain, nerves, muscles, kidneys, heart, liver, eyes, ears or pancreas, according to information from the Cleveland Clinic in Ohio.

Although the vaccine court determined that the five vaccines administered when Hannah was 19 months old worsened her underlying mitochondrial disease, Paul Offit, MD, chief of infectious diseases at Children's Hospital of Philadelphia, questioned whether that is even possible. "It doesn't make sense for a number of biological reasons."

"The challenges we face during the day in terms of eating non-sterile food and breathing non-sterile air are much greater than one ever encounters in vaccines," said Dr. Offit. Many studies have concluded vaccines don't weaken the immune system, he said.

Timothy Doran, MD, chairman of the Dept. of Pediatrics at Greater Baltimore Medical Center, noted that the court, established by the National Childhood Vaccine Injury Act, is a no-fault system designed to compensate for any possible relationship between vaccines and ill health. It doesn't look at causality, he said.

The role of the special vaccine court, which was established in 1989 to hear petitions and render compensation under the vaccine injury act, is frequently misunderstood, including by physicians.

Dr. Offit said one of his colleagues had even thought that the U.S. Supreme Court had made the ruling.

Over the years, the special court has awarded compensation in 948 cases and dismissed another 1,165. Claims considered by the court cover virtually all vaccines, with the most frequent involving DTP, diphtheria-tetanus-whole cell pertussis.

Although the Poling case may only tangentially involve autism, the disorder's link to vaccines has been occupying the attention of three "Special Masters," or vaccine court judges, since last year.

They now are gathering evidence in three test cases that represent 4,800 petitions for compensation filed over several years by families of children with autism.

These cases were combined in an omnibus proceeding, which is expected to move forward next month when the federal agency in charge of the vaccine injury act will present its views on the allegation that vaccines cause autism.

Meanwhile, Dr. Doran would like the government to shed more light on the Hannah Poling case.

"The award to her family creates confusion among the families of infants ready to receive vaccines," he wrote in a March 17 op-ed piece for the Baltimore Sun newspaper. "A few days ago, a mother of one of my patients, herself a doctor, asked me why the government had made the award if the vaccines were not the cause of autism."

"I think the award was probably OK," said Dr. Doran. "Maybe the girl's mitochondrial disease got worse after the vaccines. Whether she has autism or a mitochondrial deficiency, we don't know."

Genomic science may one day provide the answer to whether vaccines do pose a risk to certain children, noted Dr. Cooper. But we aren't there yet.

"It would be wonderful if our immunization recommendations were not one-size-fits-all," he said. "But for now, for the greatest good for the greatest number of children, it is the only approach we can take."