Arsenic and Old Lace Does Not Vaccine Injury Make

Arsenic and Old Lace

In 1939, playwright Joseph Kesselring wrote a play titled Arsenic and Old Lace, which was made into a film released in 1944. The basic plot of the comedy surrounds a family whose members are insane killers, including two elderly aunts who give their elderly male guests elderberry wine laced with arsenic, strychnine and cyanide, then bury the bodies in the basement. It is a classic piece of theatre and film, whose events may have been inspired by the sort of real life events discussed in Deborah Blum's book, The Poisoner's Handbook.
While the events of the play set the stage for a dark comedy, the real-life equivalents are no laughing matter. In fact, as recently as 2010, someone in Maine poisoned members of their church by lacing coffee with arsenic. Sixteen people tried the coffee, complaining of its bitter taste. Symptoms came on quickly, causing thirteen of the coffee drinkers to seek medical attention, with eight of them requiring hospitalization. One person died from acute arsenic poisoning. The perpetrator committed suicide five days after the event. It's an example of the deliberate contamination of something normally benign to inflict serious injury and death. No reasonable person would look at this incident and claim that coffee is harmful and should be avoided.

Anti-vaccine activists, on the other hand, aren't exactly reasonable people.

The other day, a Twitter user by the 'nym @MannyQuinn23 posted the following comment:

Vaccines are bad - here's a link unrelated to vaccine injury!

The text reads, "u should own that vax can b dangerous." He includes a link to a story in the U.K.'s The Telegraph entitled "Dozens of children feared dead after being injected with 'tainted’ measles vaccine in Syria". The news article describes a horrific event in Syria, in which several dozen children died in recent days after receiving a measles vaccine, with many others in serious condition. The children all received immunizations from the same vials that are part of the Syrian opposition coalition's and the World Health Organization's effort to ensure that the trouble region does not see an outbreak of measles. The risk of measles is very high for a number of reasons. The country is in a state of civil war, meaning that infrastructure and healthcare efforts are compromised. If anyone falls ill with measles, the risk of serious complications or death increase dramatically. Measles is also endemic in much of the region, so the risks of infection are also high. That situation is made worse as people congregate for protection. And once an outbreak starts, it can be spread to neighboring countries, or even overseas, by refugees fleeing the area. Getting children immunized is one of the most effective and least expensive means to preventing a major outbreak with dire consequences in that sort of setting, so an incident like this has major ramifications for public health in the country and, indeed, the world.

But is it an example of how vaccines cause injury? Does it support the anti-vaccine message that vaccines are bad? Not by any means.

While it's not clear, yet, exactly what happened with the vaccines, the article linked to by Manny Quinn suggests possible cyanide poisoning, with two 40-dose vials being suspected as having been tampered with. If they were tampered with, the intent appears to be to make people distrust the Syrian opposition coalition. As the investigation moves forward, and if it turns out that someone did sabotage the vaccines, the most severe criminal charges should be brought against those responsible. The worst part of all this is the painful death of so many children. Children should be protected as much as possible. That is one of the driving forces behind this blog, so to see such a horrific betrayal as the possible mass murder of children infuriates me and makes me incredibly sad. But the impact goes far beyond the death and injury of these children. The immunization program is on hold, delaying measles protection to hundreds of thousands of children. And even once the program resumes, there will be a high level of distrust. Fear of the vaccine has been instilled, and that is very difficult to overcome.

Claiming this event as evidence in support of an anti-vaccine ideology is an insult to the suffering of these kids and their families. It is a very cynical exploitation of tragedy for personal, self-righteous justification of a dangerously erroneous viewpoint. Manny Quinn dug his hole even deeper by taking umbrage at being called out for his shameful misuse of this tragic event to further his message that vaccines are the root of all evil:

"I know you are but what am I?"

He writes, "I'm exploiting child?but vax injured kids are sacrificed by u for 'the greater good?' Hypocrite?"

Here's the thing. I readily acknowledge that vaccines do have risks and that real vaccine injuries do happen. They are very rare (on the order of 1 in a million odds - you're more likely to be injured in a car accident than you are by a vaccine). Yet each one is tragic, and we should always be doing out best to prevent harm from what is meant to protect children and the people around them. But I also know recognize that the risks of diseases are significantly higher than the risks of the vaccines. The benefits to vaccination far outweigh their risks. A person who gets the measles has a greater chance of death or serious injury from that (1 in 1,000-3,000 odds of dying from measles in a developed country) than their lifetime risk of dying by choking on food (about 1 in 3,649).

At this early stage, however, we don't know for certain what happened. Another news article notes that the symptoms suggest contamination. The Guardian reports that the rebel health ministry suspects foul play by saboteurs who have been targeting the medical sector recently. There have also been accusations of neglect and mishandling of the vaccines, including suggestions that the vaccines were expired. Yet, other vaccine vials from the same lot were used without incident to immunize 60,000 other children in 30 locations around the country.

The symptoms, reported by The New York Times, have included "tightness of breath, slowed heart rate, wheezing and inflammation of the larynx". Those symptoms are not what would be seen with expired vaccine or vaccine stored at the wrong temperature. Storing the vaccine at too warm or too cold a temperature renders it ineffective, but generally would not increase the risk of adverse effects. It is incredibly unlikely that the vaccine itself is to blame.

A more likely explanation is contamination. The question is with what. One possibility is contamination with Staphylococcus aureus. According to the WHO:

Contamination of reconstituted measles vaccine with Staphylococcus aureus has been documented in several case histories in different countries. Children immunized with contaminated vaccines become sick within a few hours; local tenderness and tissue infiltration, vomiting, diarrhoea, cyanosis and high temperature are the most frequent symptoms. Events are usually associated with immunization from one vial, while many other doses of the same lot are administered in the same or other countries with no reactions. These incidents, which result in needless deaths or life threatening illness, and damage to immunization programmes, are completely preventable if proper reconstitution of vaccines and proper handling procedures are followed.

Some of the symptoms of S. aureus sound similar, but without more details and the results of lab tests, we cannot say whether or not this was the cause.

The New York Times article also reports Dr. Mohammad Hamadi suggesting a possible mix up with the diluent. Dr. Hamadi notes that vaccinators may have mistakenly mixed it with Atracurium, since the bottles are similar in appearance:

This image shows a 1-dose vial of MMR II (image from Merck), a 10-dose vial of MMR and sterile water diluent (image from WHO) and vials of Atracurium (image from Bedford Labs). Atracurium is a muscle relaxant used during surgery, in conjunction with anesthesia. It is stored at the same temperature range as MMR vaccine (2°C - 8°C). Given the chaotic state of things in Syria, with infrastructure disrupted and possible shortages of supplies, the drug could conceivably have been stored in the same refrigerator as the vaccine (which is against recommended practice), increasing the risk of mistakenly using the wrong vial. Symptoms of Atracurium overdose are muscle paralysis, histamine release and hypotension (low blood pressure). But it doesn't take an overdose to cause some of the symptoms reported, such as wheezing, bradycardia (slow heart rate). [Edited to add (9/18/14): An article from The Guardian late on Sept. 17 mentions a preliminary report finding this mix up to be the cause and puts the confirmed death toll at 15, rather than 36-50, with 75 others injured.]

As for the sabotage hypothesis, there are several ways that could have been accomplished. The vaccines were shipped to Turkey and from there to northern Syria. Anywhere along the route, the vaccines could have been intercepted and tampered with. Tampering with the vials themselves (opening, spiking and resealing them) would likely have left visual evidence. Alternatively, some contaminated vials may have been prepared ahead of time and swapped into the shipment. It is also possible that the vaccine vials were tampered with after being opened and reconstituted. This would probably have required the saboteur being on the inside.

This is, of course, speculation. Blood samples have been sent off, and we will need to wait until those results are back to find out what really killed those children. That will still be several days away. If this is due to accidental contamination, the system in Syria must be reexamined to ensure this doesn't happen again. If it is the result of intentional poisoning, I cannot imagine a punishment that is too severe for the perpetrators. Ultimately, this will have a very long-lasting negative impact on efforts to control communicable diseases in the region, if not the world. Whether the result of accident or murder, trust in the system has been hit hard. Even if steps are taken to prevent such a tragedy occurring again, the fear is there and will be very hard to counter. The immunization program will likely falter, and measles will become even more of a threat than it already is.

To bring this back to Manny Quinn and his tweet, what it boils down to is this: Saying that vaccines, in general, cause harm because someone tainted a couple of vials with cyanide is like saying coffee, in general, causes harm because someone laced a pot of coffee with arsenic. It is dishonest and disrespectful to those who suffer real harm and injury. But such is the way with those ideologically opposed to vaccines, who blame vaccines for "stealing" their children and cannot accept the real child before them. Count on them to spin this story to scare parents away from vaccinating their children against measles, but don't expect them to publish any corrections if it's shown the vaccine isn't to blame.

[UPDATE (10/1/14): An interim report has been released on this incident. I have a new post discussing it here.]
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News articles on the incident

• The Guardian (UK) - At least 34 Syrian children die from contaminated measles vaccine (Sept. 16, 2014) 
• The Guardian (UK) - Measles vaccination mix-up leaves 15 infants dead in northern Syria (Sept. 17, 2014)
• The Independent (UK) - Syrian crisis: Rebel government claims dozens of children killed by contaminated measles vaccine (Sept. 17, 2014)
• New York Times (USA) - Bad Vaccine Kills Dozens of Children Inside Syria (Sept. 17, 2014)
• The Telegraph (UK) - Dozens of children feared dead after being injected with 'tainted’ measles vaccine in Syria (Sept. 16, 2014)
• UNICEF - Joint WHO – UNICEF statement regarding deaths of children in Idlib, northern Syria (Sept. 17, 2014)