Dog getting injection

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A veterinarian who practices alternative medicine in my area recently told our mutual client she shouldn't get her next rabies vaccine if she didn't want it to be the last decision she made for her 15-year-old dog. As it was the client who told me what he said and I would be the one giving the vaccine, not the other doctor, I reached out to this veterinarian asking about the discussion. He responded saying he felt it was his obligation to educate her about the potential adverse effects, and sent me a link to a 2016 Dr. Jean Dodds paper from the journal Global Vaccines and Immunology. 

In addition, he sent a link from The Rabies Challenge Fund, an organization co-founded by Dr. Dodds. The Rabies Challenge Fund is trying to determine the duration of immunity conveyed by rabies vaccines. Their goal is to extend the required interval for rabies boosters to 5 and then to 7 years. I think this is a worthy goal, however, we want to make sure we have good evidence before we make those changes.

I responded with another letter.

Dear Alternative Doctor,

Thank you for responding. I apologize for taking so long to get back to you. I read the article and website you sent and did some research and came to different conclusions from yours. Our mutual client is open to learning and reading, so I would like to share my research with both of you.

The article you referenced from Global Vaccines and Immunology starts off with many true and uncontested statements, as Dr. Dodds often does in her articles. The abstract, which is the only thing you might see if you searched for the article, does not mention adverse effects of vaccines. This seems disingenuous because her main point in this article seems to be that adverse effects of vaccines should receive more attention.

Is that journal reliable?

My first question: is this a journal that is reputable? Open access journals are proliferating, as the internet makes ever more information instantly accessible. These journals can speed information or can be a way to avoid scrutiny. I found two ways to check. The first is a list of potentially “predatory” journals and publishers; a predatory journal charges money from authors to publish, and may not subject the article to review by other scientists. Beall’s List is a list of potentially predatory journals and publishers of journals: Open Access Text is the publisher of Global Vaccines and Immunology, and is listed as a predatory publisher, charging 2000 GBP (pounds sterling, or almost $2,500) per article. The second way to check if a journal/publisher is reputable is membership in the Open Access Scholarly Publishers Association, an association that reviews open access journals to make sure they maintain high standards. The journal that has the article originally referenced, Global Vaccines and Immunology, is not a member of OASPA.

Thus, I realized that this article was in a journal that may not have strong peer review standards, and may just be making money by charging the authors and allowing scientists to self-publish their work without scrutiny. That publishing route is at the opposite end of the gold-standard spectrum of the peer-reviewed journals that have been subjected to scientific scrutiny.

Are there adverse effects of rabies vaccines?

Any vaccine may produce allergic reactions, up to and including fatality, but these are rare. In the article, most of the adverse effects noted are associated with aluminum or mercury, often called thimerosal. The rabies vaccine we use does not contain aluminum or mercury. In human medicine, a connection between adjuvants (specifically aluminum) and autoimmune disease was postulated (autoimmune autoinflammatory syndrome induced by adjuvants [ASIA]). Subsequently, two studies were identified that refuted this claim (e.g. the presence of aluminum in a vaccine was not connected with worsening of an underlying autoimmune disease). The authors concluded that current studies don't support the existence of ASIA. A reference from the Children’s Hospital at the University of Pennsylvania, a world-renowned medical center, says “The authors concluded that current studies do not support the existence of ASIA.”

In human medicine, a connection between adjuvants (specifically aluminum) and autoimmune disease was postulated by ASIA. Subsequently, two studies were identified that refuted this claim (e.g. the presence of aluminum in a vaccine was not connected with worsening of an underlying autoimmune disease). The authors concluded that current studies don't support the existence of ASIA.

Next, when I searched for the authors of the ASIA studies, I found that they had retracted at least two papers. This is unusual, and indicates a concern for relying on their papers. 

My conclusion is that the association of chronic autoimmune neurological problems with rabies vaccines has little evidence.

What about using titers instead of revaccinating?

Titers are levels of antibodies in an individual that may be used to determine if that individual is protected from a disease. Challenge studies are the gold standard, where individuals are exposed to the disease, and we can see if the antibody levels protect them. The data show that even the recommended cutoff level of presumed protective antibodies used for international travel is not protective in all cases, although previous vaccines do allow for rapid increases in titers. In rabies, I’m unwilling to accept less than 100% efficacy in challenge studies. The disease is fatal, untreatable, and horrible.

There are very limited published data on dogs and cats out-of-date for their rabies vaccination and survival from challenge. One study described dogs (5 years post-vaccine) and cats (4 years post-vaccine), who had their rabies antibody level checked just before challenge: 54% of dogs and 87% of the cats had detectable antibodies to rabies. After challenge with active rabies virus, 92% of the dogs survived and 100% of the cats survived.

Even The Rabies Challenge website is not recommending titers:

In order to protect animal and public health, we assert that animals should only be vaccinated against rabies as often as necessary to confer/maintain immunity and to avoid any unnecessary risk of vaccinal adverse reactions. It is also The Rabies Challenge Fund’s position that antibody testing by a federal or state approved lab is an important measure to assure protection against rabies. Until adequate data exists supporting a specific antibody threshold at which animals are demonstrated to be immune to rabies challenge, we believe it is premature for state rabies laws/regulations to allow for titers in lieu of vaccination.

The data from The Challenge Fund has yet to be published three years later, even though it was mentioned in many veterinary news articles prior to peer review. So, did it not pass peer review? We don’t know.

Dr. Jean Dodds, RCF Co-Trustee and Principal Investigator, and Dr. Ronald Schultz of the University of Wisconsin School of Veterinary Medicine, will be preparing results of the study and details described above for scientific peer review and publication. That data will be made available to the public as soon as our paper has been accepted for publication. After completion of the peer-review process, it is our hope that this data will establish the world’s first canine rabies titer standard. If this data is further verified by the challenge phase study results, it will provide a solid scientific base enabling states to incorporate rabies serum antibody titer clauses into their laws.

Many state legislatures have updated their rabies laws to reflect the science that was previously available; that is important and has reduced animal suffering from rabies. Our state of Massachusetts updated its laws to booster vaccines in outdated animals potentially exposed to rabid wildlife. See the relevant article from the respected Journal of the American Veterinary Medical Association. 

Conclusions and Clinical Relevance
Results indicated that dogs with out-of-date vaccination status were not inferior in their antibody response following booster rabies vaccination compared with dogs with current vaccination status. Findings supported immediate booster vaccination followed by observation for 45 days of dogs and cats with an out-of-date vaccination status that are exposed to rabies, as is the current practice for dogs and cats with current vaccination status.

What I conclude from this is that titers are not likely to guide our decision making, and if we knew that Sweet Elderly Dog was exposed to a rabid animal and she was overdue on her rabies vaccine we could protect her, but she, and her family, might not be protected if she was exposed to a rabid animal and we didn’t know it.

We have had a few clients whose cats were overdue on rabies vaccines and a bat was found in the house. It was unnecessary stress for the cats and the clients, and the board of health got involved. We had to vaccinate all the cats and all the people in the house had to get vaccinated.

Vaccine fears

I wanted to share this article about the history of the anti-vaccination movement that may be helpful to you in understanding why I am so concerned about your recommendation not to vaccinate Sweet Elderly Dog for rabies. It is also from an open access journal, but it is not on the list of predatory journals, and it is listed on the OASPA.org website as having strict guidelines and peer review.

The Anti-vaccination Movement: A Regression in Modern Medicine
There have been recent trends of parents in Western countries refusing to vaccinate their children due to numerous reasons and perceived fears. While opposition to vaccines is as old as the vaccines themselves, there has been a recent surge in the opposition to vaccines in general, specifically against the MMR (measles, mumps, and rubella) vaccine, most notably since the rise in prominence of the notorious British ex-physician, Andrew Wakefield, and his works. This has caused multiple measles outbreaks in Western countries where the measles virus was previously considered eliminated. This paper evaluates and reviews the origins of the anti-vaccination movement, the reasons behind the recent strengthening of the movement, role of the internet in the spread of anti-vaccination ideas, and the repercussions in terms of public health and safety.

There is also evidence that concerns about vaccines has been worsened by Russian influence: Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate.

Rabies is really serious

Rabies is a terrifying disease. Vaccinating against it is one of the most important ways veterinarians protect people. That’s why the laws about rabies vaccines are overly conservative. In veterinary school, one of the best lectures I had was by a professor who had been exposed to rabies four times, each time more dramatic. He had many vaccines in his life, starting in the Philippines in World War II. For a graphic example of how terrifying this disease can be, you could listen to a podcast or read the transcript of one of my favorite shows, Radiolab, about a human case that was successfully treated, a very rare occurrence. 

So, what to do?

Clearly, there are risks to any medical procedure, just as there are risks to not vaccinating. Vaccines can have adverse effects, but they are rare. Our Massachusetts laws allow for medical exemptions, although I am not convinced these apply to Sweet Elderly Dog. I would avoid or delay a vaccine in cases where my patient was undergoing chemotherapy or treatment for an autoimmune disease, then vaccinate them as soon as possible after their immune system recovers. The Massachusetts law says the exceptions are for a specified period of time, not just never again. Our hospital has chosen to follow the letter of the law with regard to rabies vaccines, to protect our patients, our clients, and our staff.

I have shared this information with our mutual client, and I appreciate your willingness to continue the dialogue. I appreciate working together to help our patients live their best lives, and I know both of us are doing our best.

Sincerely,

Sweet Elderly Dog’s Regular Veterinarian

So far, I’ve not heard back from Alternative Doctor, but I’ll let you know if or when he does. Sweet Elderly Dog had her rabies vaccination at my clinic on the day it was due, and has had no issues in the following few weeks.