Feb 29 2008

Has the Government Conceded Vaccines Cause Autism?

No. But David Kirby and other anti-vaccinationist ideologues and members of the so-called mercury militia would like you to think so. For background, the Autism Omnibus refers to a set of hearings before the Vaccine Injury Compensation Program regarding claims by about 5000 parents that their childrens’ autism was caused by vaccines. These claims are primarily based upon the various hypotheses that the MMR vaccine, or thimerosal in some vaccines (but not MMR), or the combination of both, is a cause of autism.

So far there have been hearings, but only one final decision. In November the US government settled one case in favor of the petitioner. This is the case those who have supported the failed hypothesis that vaccines cause autism now point to as admission that they were right all along (or at least as a means of stoking the flames of fear about vaccines.) But the US government did not admit vaccines cause autism – they conceded one case that is highly complex and not necessarily representative of any other case and cannot be reasonably used to support the vaccine/autism connection.

David Kirby, author of Evidence of Harm, wrote a highly misleading article the other day in the Huffington Post on this issue. Orac has already done an excellent job of tearing down Kirby’s claims. He points out that legal cases are often decided for legal – not necessarily scientific – reasons. That the government only conceded that “compensation is appropriate.” That is all – they conceded nothing about the larger question of vaccines and autism. Orac also points out that if this case were a concession of a connection why would the petitioner’s lawyers settle and give away a case that could win them all their other cases?

David Kirby has also written a follow up article, where he publishes verbatim the US government’s decision. Kirby asks his readers:

If you feel this document suggests that some kind of link may be possible, you might consider forwarding it to your elected representatives for further investigation.

But, of course, if you feel that this document in no way implicates vaccines, then let’s just keep going about our business as usual and not pay any attention to all those sick kids behind the curtain.

I think Kirby is hoping that most people will not have the patience or medical background to read and understand the entire document, and that they will come away with a vague notion that there must be something to all this vaccine fear-mongering. What does the document really tell us?

To summarize the case history, the child in the case appeared normal and healthy, except for chronic otitis media, until about 20 months of age at which time he had a series of vaccines according to the routine vaccination schedule. Two days later the child had a fever to 102.3, was lethargic, irritable, and would arch his back when he cried. The child then developed a rash. It was later determined that the child had: “encephalopathy progressed to persistent loss of previously acquired language, eye contact, and relatedness.” The child regressed and developed symptoms similar to those of autism spectrum disorder. However, the child does not have autism – he has a regressive neurological disorder that includes blood and muscle abnormalities not seen in autism, and any clinical resemblance to autism is not a reflection of a common cause.

Six years after symptoms began the child also developed partial temporal lobe epilepsy that required treatment.

During this time the child also had an extensive workup, which discovered:

A CSF organic acids test, on January 8, 2002, displayed an increased lactate to pyruvate ratio of 28,1 which can be seen in disorders of mitochondrial oxidative phosphorylation.

A muscle biopsy test for oxidative phosphorylation disease revealed abnormal results for Type One and Three.

In February 2004, a mitochondrial DNA (“mtDNA”) point mutation analysis revealed a single nucleotide change in the 16S ribosomal RNA gene (T2387C)

It if often difficult or impossible to draw firm conclusions from a single case, so I will lay out what I see as all the possible alternative hypotheses to explain this information.

1) One possibility is that the child was perfectly normal prior to the vaccines, which caused an encephalitis (inflammation of the brain) which caused brain damage, including the later seizures. The metabolic disorder and mutation may be a red herring and have no bearing on the child’s clinical condition.

2) The mitochondrial disorder predisposed the child to have a reaction from the vaccines, resulting in encephalitis. The subsequent neurological regression was due to some combination of the vaccine-induced encephalitis and the underlying mitochondrial disorder.

3) The child’s mitochondrial mutation is the primary cause of their neurological regression, but that this regression was exacerbated by the vaccine-induced encephalitis (this seems to be the US government’s conclusion).

4) The child has a mitochondrial encephalopathy which is the sole cause of all of the child’s neurological signs and symptoms. The reaction to the vaccines may have played no role at all in the subsequent regression, and the child’s current neurological condition is exactly what it would have been had they never been vaccinated. It is even possible that the encephalitis was merely the first manifestation of the mitochondrial disorder and the timing after the vaccines was merely coincidental.

That lays out the spectrum of possibilities in this case. At this point in time we do not have (or at least I am not privy to) sufficient scientific information to say definitively where along this spectrum the truth lies. The US government’s decision was based partly on this uncertainty – erring on the side of compensating the child and family.

But we can discuss the plausibility of each scenario. Kirby dismisses anything resembling option 4, but his dismissal is naive and unjustified. In fact the patient’s clinical syndrome resembles what is called a mitochondrial encephalopathy – with increased lactic acid, abnormal muscle biopsy, neurological regression, appropriate age of onset, even seizures. It is probably not a coincidence that the child has a point mutation in a gene that has been previously linked to these very mitochondrial disorders. Kirby incorrectly argues:

While it’s true that some inherited forms of Mt disease can manifest as developmental delays, (and even ASD in the form of Rhett Syndrome) these forms are linked to identified genetic mutations, of which T2387C is not involved. In fact little, if anything, is known about the function of this particular gene.

This is misleading. Kirby refers to “this particular gene” which makes me think that he believes T2387C is a gene. It’s not – it describes a point mutation (at location 2387 a thymidine has replaced a cytosine). The gene is the 16S ribosomal RNA gene. Mutations in this gene have been identified to cause mitochondrial encephalopathy. So Kirby is just wrong. It is true that I could not find that this specific mutation has been identified before, but that is common in genetics – a disease is linked to point mutations in a specific gene (or perhaps specific regions of a gene) but most or all families identified have their own specific mutation.

This makes option 4 very plausible – it would be an incredible coincidence if this child just happened to have a mutation in a gene that was known to cause their exact constellation of neurological signs and symptoms and yet the mutation was not the sole or primary cause of those symptoms.

But it does not rule out option 3 – that the mitochondrial disorder was the primary cause of the child’s neurological disorder but that a reaction to the vaccines worsened the ultimate symptoms. Therefore the government’s decision was reasonable – but is absolutely not a concession about any claim made by the petitioners concerning a link between vaccines an autism.

It does, however, make any hypothesis resembling option 1 or 2 extremely unlikely. Further testing regarding the physiological effects of this child’s specific mutation would be helpful, and such testing may be under way but I could find nothing published to date. It is theoretically possible that the identified mutation does not cause a change in the gene product or mitochondrial function, and is therefore just a coincidence. But this is unlikely given the clinical features in this case are a good match to known mutations of that gene.

Kirby, however, apparently wants to wring as much fear and confusion out of these events as he possibly can. So now he speculates wildly that maybe children diagnosed with autism really have this mitochondrial disorder combined with vaccines (he has to keep vaccines in the loop). Given the rarity of such mutations, and the fact that there were specific features in this case that would likely be uncovered in the routine evaluation of a child with autism (like an elevated lactic acid), it is highly unlikely that there are many children with vaccine-triggered mitochondrial encephalopathy mimicking autism out there.

It has been found that some children with autism have mitochondrial dysfunction – one study found that 7.2% of subjects with autism had “definite mitochondrial respiratory chain disorder.” Poling et al, in response to this child’s case, did a retrospective study of children with autism and with other neurological disorders and found that “Aspartate aminotransferase was elevated in 38% of patients with autism compared with 15% of controls.” Such findings are preliminary – the only conclusions that can be drawn is that the association between autism and metabolic disorders requires further investigation. However, these studies did not look at the incidence of suspicious mitochondial mutations in autism, and these findings may not be relevant to this case.

Kirby also wildly speculates that perhaps the evil toxins in vaccines caused the mutation in the first place. He writes:

Use of the AIDS drug AZT, for example, can cause Mt disorders by deleting large segments of mitochondrial DNA. If that is the case, might other exposures to drugs or toxins (i.e., thimerosal, mercury in fish, air pollution, pesticides, live viruses) also cause sporadic Mt disease in certain subsets of children, through similar genotoxic mechanisms?

Among stiff competition, this is perhaps the most absurd and scientifically ignorant thing Kirby has every written. AZT does NOT cause a genetic disorder. AZT blocks DNA replication (it blocks the copying of DNA) – that is its mechanism as an anti-retroviral drug. In patients it can also block mitochondrial DNA replication, thereby causing mitochondrial depletion. This results in there being too few mitochondria (the energy factories of cells) in some cell populations and causes dysfunction in tissue that is especially susceptible to the effects of this dearth of mitochondria. This is a side effect of AZT and also other retrovirals because of sustained use at doses designed to inhibit DNA replication. This does result in some effects that are similar to mitochondrial genetic disorders – because both result in insufficient mitochondrial activity. But that is the only similarity. AZT does not cause a disseminated somatic mutation, which is the incredible analogy that Kirby is making.

What Kirby is suggesting is that in infants and toddlers toxins can cause the same point mutation in millions of different cells throughout the body. Toxin-induced mutations do not cause genetic diseases, unless they occur in a germ cell in which case a mother or father can pass the mutation onto their children. If it occurs in the womb then large cell populations may be affected (whatever cells derive from the cell that had the mutation). But in a child a point mutation would affect only one cell and any cells that derive from it. A toxic mutagen would cause different random point mutations in different cells. This could not cause the mitrochondrial encephalopathy in this child. It can increase the risk of cancer, because cancer can develop from a single mutation in a single cell that causes it to become neoplastic.


This is a unique and idiosyncratic case that raises more questions than it answers. In my opinion as a neurologist, with the information provided, the child has a mitochondrial encephalopathy. The role of the vaccines is unclear, but at worst a rare vaccine reaction exacerbated the underlying mitochondrial disorder. This case has no clear implication for the larger question concerning vaccines and autism, which is likely why both sides agreed to settle.

Yet those who insist, despite the evidence, on claiming that vaccines or mercury are linked to autism are likely to add this permanently to their litany of misinformation and fear-mongering.

Note: I am searching for any follow up information pertinent to this case and will post any addendum here.

66 responses so far

66 thoughts on “Has the Government Conceded Vaccines Cause Autism?”

  1. mjrobbins says:

    Really nice post.

    To be honest, I’m not so worried about the anti-vaccination sites and groups. What scares me most of all are the mainstream media outlets that are continuing to use any excuse to wage a subtle anti-science campaign (see for example Britain’s notorious “Daily Mail” – http://layscience.net/?q=node/29 ).

    Kirby’s use of science is interesting too… it seems to follow the general pattern of lots of these people who look at the scientific literature in an attempt to back up their ideas, quote words from it, but don’t really understand it. Unfortunately, that puts them somewhere above mainstream science editors in terms of their comprehension, which is worrying…

    I’m just praying we don’t have a new outbreak of MMR-hysteria in the UK :S


  2. Steve Page says:

    Bravo, sir – a great post. If I wore a hat, I’d be doffing it now.

  3. I often wear two hats so.. on behalf of Mr. Page and myself, you are double-doffed for a great post.

  4. TheProbe says:

    Unfortunately, those who will say and do anything to scare people away from vaccination will not be deterred by this brilliant post. I have made several posts in the alternative health newsgroups, and those who are anti-vaccination continue to post away.

  5. isles says:

    Thanks for this post. It’s refreshing to get the impressions of somebody who actually knows about the subject.

    The outcome of this case is entirely consistent with the purposes and structure of the vaccine injury compensation program – it is set up to provide rapid compensation to people who can show even a minimal possibility of having been injured by a vaccine. It is accepted that some will be compensated whose injuries truly did not come from vaccines – the policy judgment is that providing this level of assurance (that real vaccine injuries will be non-adversarially compensated) is worth paying out some unwarranted claims.

    It seems like in this case, the regression likely would have occurred with or without the vaccine, but in keeping with the spirit of the program, compensation was awarded based on a finding that, while many things could have triggered the regression (including nothing but natural progression of the disease), one possible trigger was vaccination. It’s just too bad the only ones who can legally speak about the case are the claimants – they’ve done nothing to dispel the inaccurate interpretation being spun by Kirby and his groupies.

  6. daedalus2u says:

    There are some physiological reasons why mitochondrial disorders are associated with autism like symptoms. I think the main reason is because most all mitochondrial disorders result in a low NO state (which can become self-perpetuating).

    Mitochondria are the organelles that produce most of a cell’s ATP, and are the only way that cells can produce ATP via oxidative phosphorylation. Electrons and protons are taken from organic substrates, passed between the different respiration complexes which are all membrane bound and finally the electrons are shuttled off onto O2 by cytochrome c oxidase making 2 molecules of H2O (a 4 electron reaction). This movement of electrons and protons generates an electric field and a proton gradient across the membrane. Another complex (F0/F1 ATPase) then generates ATP from the energy in the proton gradient.

    Normally cytochrome c oxidase is inhibited by NO, which blocks O2 reduction. This inhibition is extremely important because it is what allows O2 consumption (and hence ATP production) to be distributed among the thousands of mitochondria in each cell and among the hundreds of cells in the vicinity of a capillary. Without that inhibition the mitochondria closest to the O2 supply would consume it all.

    Mitochondria can produce ATP at different rates. To produce it at a higher rate, requires a higher membrane potential to drive the F0/F1 ATPase faster. When the membrane potential is increased, there is increased generation of superoxide which reacts with NO at near diffusion limited kinetics. This pulls the NO level down, this disinhibits cytochrome c oxidase and O2 is consumed to a lower O2 concentration, the gradient of O2 from the blood vessel to the mitochondria increases so the flux of O2 down that concentration gradient (via passive diffusion) increases.

    Anything that reduces the number of effective mitochondria is going to push those that remain to a higher potential and induce a low NO state. In the short term this is good because it increases O2 diffusion to the mitochondria, but in the long term it is bad because what triggers mitochondria biogenesis is NO via activation of sGC.

    This is how a mitochondrial depleted state can become self-perpetuating. Low NO reduces mitochondrial biogenesis which (if maintained for a long enough time) depletes mitochondria number sufficiently that the remaining mitochondria produce enough superoxide from their high potential to reduce NO levels and mitochondria biogenesis. The only way to correct this is via an external source of NO (that would be the normal basal NO source).

    There are some mechanisms by which a low NO state can increase the gain on the immune system. NO inhibits NFkB which is the main transcription factor regulating inflammation. Low NO causes NFkB to express more immune factors when it is activated. This can activate what I call the “low NO ratchet” because one of the factors expressed by NFkB is iNOS, which produces very high levels of NO, but is only expressed transiently. But high levels of NO cause reduced expression of eNOS and nNOS which are expressed constitutively. They produce less NO, the basal NO level is lower, the next time the immune system is activated NFkB causes more iNOS and another turn of the low NO ratchet. I discuss this in more detail on my blog explaining the mechanism by which fevers acutely (but transiently) resolve some of the behavioral symptoms of autism.


    I think there are also some prompt NO mediated functional connectivity effects important in maintaining the autism phenotype via low NO in the brain. I think these are similar to the effects of neuroinflammation which fever therapy was used to treat 75 years ago. NO from iNOS from malaria resolved the symptoms of neurosyphilis (but with non-negligible side effects).

    I think the low NO ratchet holds for a number of other disorders exhibiting exercise intolerance, which is a sure sign of not enough mitochondria. If you don’t have extra mitochondrial ATP production capacity, you can’t increase your metabolic rate above what the mitochondria you do have can supply. I think that is what chronic fatigue syndrome is (not enough mitochondria in the muscles). I think that most degenerative diseases result from not enough mitochondria in the target organ. When that target organ is the CNS, you get the various neurodegenerative diseases. It is actually a bit more complicated than that, but close enough for a first approximation, and why many of the symptoms of mitochondrial disorders mimic those of the metabolic syndrome, dilative cardiomyopathy, fatigue, excess lactate, etc.

  7. whereisthelogic says:

    So the ‘question-vaccines’ advocates are accused of fear mongering, while several of your posts warn of a future MMR epidemic if we do not blindly continue to vaccinate our children–in spite of the fact that we know a whole lot more about treating these ‘deadly’ diseases than we do about the interaction between vaccine injections and the developing neurological system. Better watch who is fanning the flames. Martin.

    My hope is that I am wrong and you are right, and the medical establishment has, after 200 years or so, finally finished ‘fine tuning’ these vaccines so they really are safe.

  8. whereisthelogic – ironically has given us a string of non sequiturs.

    False fears of a link between the MMR vaccine and autism resulted in a decrease in MMR compliance in Great Britain which was followed by a resurgence of these diseases. It happened. It is not fear mongering to warn that it could happen again from unfounded vaccine fears.

    No one is “blindly” vaccinating children. Vaccines are extensively researched, and continue to be researched. They are strongly evidence-based.

    The effects of vaccination are widely studied – including any possible connection to neurological disorders. The evidence strongly shows there is no connection.

    I don’t think we are done “fine tuning” vaccines. Why should we be? Medicine is an applied science, and is constantly improving and reexamining its evidence. The “fine tuning” never stops.

    And safety in medicine is always relative – you have to consider risks vs benefits. No intervention is without risks, and “safety” is not a black and white issue. What has been overwhelmingly established by evidence is that the benefits of vaccines far outweigh the risks.

  9. bamon says:

    Thanks for sharing your perspective. The blogosphere appears split on this possible link. I’m concerned and don’t know for sure whether the link exists, but I will be cautious.

    Anyway, I linked to this post on Qvisory yesterday. Thanks again for sharing.

  10. Jon,

    Thanks for the additional information. It confirms my opinion that this case is complex and generates more questions than it answers, and certainly cannot be used with current knowledge as a precedent for the conclusion that vaccines cause autism.

    Regarding thimerosal, since this was removed from all routine childhood vaccines by early 2002 the question of whether or not to expose kids to thimerosal is no longer an issue. The fact that the current evidence shows that removing thimerosal did not decrease the rate of increase in autism diagnoses (replicated in other countries as well) means that thimerosal is not a significant contributor to the total number of autism cases, and was not responsible for the increase in autism rates over the last 20 years. Of course it is correct that such studies can never rule out a small effect – they can only set limits on how large an effect statistically is likely, but the data certainly rules out a significant effect from thimerosal and contradicts the predictions of many anti-vaccine activists that thimerosal was responsible for an epidemic of autism.

    The possible connection between mitochondrial dyfunction, genetic predisposition, and vaccine (or other) trigger is interesting and certainly deserves to be further studied. But this cannot and should not be used to justify prior claims that autism is essentially misdiagnosed mercury poisoning.

  11. With all due respect, Mr. Novella, thimerosal has not been removed from all vaccines. Please read Professor Boyd Haley’s response to the Schechter-Grether paper at http://www.vaccinationnews.com/boyd_haley_1-8-08.htm.

    Also, as you can see here (http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf) the CDC knows there is still thimerosal in vaccines, even if you do not.

    And although there may be “only” trace amounts left in many vaccines, unless you can provide studies that prove otherwise, it is not known exactly how much thimerosal is required to trigger autism in susceptible children.

  12. My apologies, Dr. Novella for accidentally typing “Mr.”

    Here is the FDA page on thimerosal, which you might also want to review: http://www.fda.gov/cber/vaccine/thimerosal.htm


  13. autism123 says:

    What I see is simply this, Hannah had 9 vaccines after which she became autistic. Hannah did not become blind,deaf or dumb,she did not develop cerebral palsy,muscular distrophy or a million other possible conditions. Hannah developed the same symptoms as 4900 other children awaiting justice in the compensation court and that is no coincidence.

  14. I did not write that thimerosal was removed from all vaccines – I specifically and deliberately wrote that it was removed from all ROUTINE childhood vaccines. I implied but did explicitly state that I meant in the US. Some flu and other vaccines still contain thimerosal, but they are optional and not part of the routine vaccine schedule. The “trace” amounts that are left behind in some vaccines from the manufacturing process are too small to consider.

    The fact remains: Those claiming that mercury in vaccines was responsible for the apparent increase in autism rates in the 1990’s and early 2000’s based that claim on the increase in overall thimerosal exposure from the increased routine vaccination schedule. In 2002, when thimerosal was removed from the routine vaccination schedule (and surveys confirmed that by that time only about 2% of vaccines in pediatrician’s offices were older stocks with thimerosal). Everyone agreed at that time – both mercury believers and skeptics – that if the thimerosal hypothesis were true then autism rates should begin to decline, and dramatically so by 2006 or so.

    Well, now it is 8 years later, and the rate of increase of new autism diagnoses continues without change. This solidly falsifies the thimerosal hypothesis. But the mercury proponents have not kept to their original predictions. They keep moving the goalpost.

    Autism 123 – you are cherry picking. Hannah did develop abnormal muscle metabolism, and she also developed seizures – neither of which are symptoms of autism. Her clinical syndrome is not classical for autism, it has “some” features of autism (features that are not specific) and some features not typical of autism. The bottom line is that the Poling case is complex and distinct and is not a good test case for the broader claim for vaccines and autism – which is probably why the plaintiff’s attorneys agreed to settle and eliminate it as a test case.

  15. kathleenseidel says:

    Dr. Novella, many thanks for your lucid deconstruction of the Respondent’s Report in this case, and of David Kirby’s disgraceful distortions.

    Dr. Poling, thank you, too, for your response. I know you’ve stated that you do not intend to answer questions posed in response to your letter to Dr. Novella, but I’m going to go ahead and put this one out there in the hope that you might reconsider your position.

    You’ve declared your COI’s in this post. Why didn’t you declare your COI’s in your article in the Journal of Child Neurology — most notably, the fact that you were father to the the subject of the case-study, and party to a pending legal claim involving precisely the issues described in it?

  16. Moe says:

    Just trying to understand all sides of this issue. Can anyone verify if this is accurate?


    As late as 2003, a review of the Physician’s Desk Reference showed that three childhood vaccines were still being made with full doses of thimerosal. Diphtheria-Tetanus-acellular-Pertussis (DTaP) manufactured by Aventis-Pasteur in multi-dose vials contained 25 micrograms of mercury, Haemophilus-influenza-Type b (HibTITTER) in multi-dose vials manufactured by Wyeth contained 25 micrograms of mercury, and pediatric hepatitis B vaccine manufactured by Merck contained 12.5 micrograms of mercury. These vaccines represented about half of the childhood vaccines available for use in the US that year.

  17. Dr. Novella,

    You may say the “trace” amounts are too small to consider, but where are the studies which prove it? We don’t even have studies comparing those receiving varying amounts of thimerosal to those receiving none, let alone biological mechanism studies showing that small amounts are insignificant.

    And even you must be aware that thimerosal was not removed from vaccines 8 years ago. Existing stocks were allowed to remain on the shelves. Besides it was only a recommendation that it be removed. We do not have any idea how much was out there and until when. On top of all that, the flu vaccine has been recommended for pregnant women and infants (and now a yearly dose for all children until age 18).

    The bottom line is we don’t know if thimerosal was really reduced to “trace” amounts and even if it was, how much thimerosal it takes to injure a susceptible child.

    Hardly the circumstances for issuing blithe assurances about thimerosal.

    By the way, there is an interesting exchange of emails between the FDA & CDC and Twyla Ramos on Age of Autism that challenges the notion that anyone really knows how much thimerosal is still in vaccines: http://www.ageofautism.com/2007/12/emails-from-cdc.html

  18. Whereisthelogic, why do you think anti-vaccine activists are “blindly vaccinating”? What can’t they see? Or is it a matter of not understanding?

  19. jtlenatures says:

    Autism: Why The Debate Rages

    CBS News.

    CBS Editor’s Note: this entry by CBS News investigative correspondent Sharyl Attkisson was first posted last June, but as the debate over autism and vaccinations rages on, it seems worthy of repeating.

    Just yesterday, U.S. health officials conceded that childhood vaccines interacted with and worsened a rare disorder that ultimately led to autism-like symptoms in a Georgia girl. Her family is set to be paid from a federal fund.
    With the first autism case now being heard in federal vaccine court in Washington D.C., it makes sense to ask: Why is anyone even still debating the possibility of a link between vaccines and autism? After all, for years, many government health officials, advisors and vaccine manufacturers have said there’s no association.
    Here are a number of reasons why the question remains open:
    1. While government scientists, advisors and pharmaceutical companies have been responsible for infinite lifesaving and life improving medical advances, they are not infallible.
    . It’s the same group that originally thought it was safe to use x-ray machines in shoe stores, gave pregnant women Thalidomide for morning sickness and once allowed mercury in medicines. They assured us Vioxx and Duract were safe painkillers, prescribed Rezulin for diabetics and then denied any of them were responsible for patient deaths. If we never questioned that group, we might not have discovered that Fen-phen and the dietary supplement Ephedra are not safe weight loss products, that antidepressants in kids can lead to suicidality and Viagra can cause blindness. The list goes on.
    . When it comes to vaccines, the same group failed to predict that the 1990’s rotavirus (diarrhea) vaccine would have to be pulled from the market after infant deaths. They encouraged use of the oral polio vaccine (eventually discontinued after it gave too many children polio). And they allowed the use of a mercury neurotoxin preservative in childhood vaccines, only to admit later that they hadn’t thought to calculate the cumulative amount kids were getting as more and more vaccines were added to the childhood immunization schedule.
    . Recent history demonstrates that too often, government health officials, mainstream doctors and pharmaceutical companies aren’t on the leading edge of alerting us to health risks; they’re bringing up the rear. Patients feel left to fend for themselves, seeking independent research and opinions on their own. They and their dogged, relentless determination have often been the catalyst that eventually brings medical dangers to the forefront.
    2. Government scientists, advisors and vaccine manufacturers often take an all-or-nothing approach to vaccinations.
    . Government officials and infectious disease experts I’ve spoken with are fearful that if vaccine side effects are better publicized, or if a link between vaccines and autism and ADD were made, the public would overreact and lose faith in the entire vaccination program. The result, they’re afraid, would be parents refusing to give their children any vaccines, leading to new, deadly epidemics of preventable diseases. That indeed would be a disaster. However, their fears have resulted in something I call an all-or-nothing approach: they tend to promote nearly all vaccines for nearly all children as equally necessary and equally safe. Yet at the same time, if asked, they agree not all vaccines are equally safe, equally beneficial, equally necessary and equally tolerated by each individual child.
    . Through the Internet and other resources, parents are now able to find research on vaccines and read it for themselves. They compare the government’s all-or-nothing approach to the research and become skeptical that the government is presenting the whole picture on vaccine safety generally.
    3. Government officials and mainstream scientists who dispel any vaccine/autism/ADD link have ties to vaccine makers.
    . There’s so much overlap among pharmaceutical companies, government scientists and advisors that the information they provide at least has the appearance of a conflict of interest. Government scientists and advisors often do not mention their connections to the vaccine industry when they provide opinions on the vaccine/autism/ADD issue.
    . One of the best examples of this is the landmark autism/vaccine study published in Pediatrics. Early in his study, the lead author, CDC’s Dr. Thomas Verstraeten, found statistically significant associations between the amount of mercury (thimerosal) exposure kids got from their childhood vaccines, and a wide range of brain disorders. However, the published version of the study (the one the authors say is accurate) found no evidence of a link to autism. Not disclosed was that Dr. Verstraeten had left CDC midstream during the study and had gone to work for Glaxo, a vaccine manufacturer. That failure to disclose was criticized in a later publication of Pediatrics, but it got little mainstream attention. Also getting little attention was a letter from well-respected scientists, also in Pediatrics, who echoed what parents of autistic children had been saying for months: they questioned the use and exclusion of certain data from Dr. Verstraeten’s study that eventually reduced the statistical ties between vaccines and neurodisorders.
    . University and government researchers and advisors often do research for vaccine companies, help develop vaccines (even profit from them), and/or are paid to consult for them. Often, these researchers do not disclose their industry ties when they publicly dispel the notion of a link between autism or ADD and vaccines.
    . Lastly, the CDC is inextricably tied to vaccine makers through contracts and other business and financial relationships that open the door for the possibility of conflicts.
    4. Non-profits which dispel any vaccine/autism/ADD link have ties to vaccine makers.
    . Non-profits that promote vaccinations have ties to vaccine makers that they often do not disclose when giving their opinions on vaccine safety. One example is “Every Child By Two.” This group contacted CBS News several years ago in an unsuccessful attempt to prevent one of our stories about the vaccine safety from airing. In forms filed for the IRS, the non-profit lists an official from vaccine maker Wyeth Pharmaceuticals as its Treasurer. It lists vaccine maker Chiron as a paid client.
    . Another example of a non-profit tied to the industry is “The Vaccine Fund.” Its President from 2000-2005 was Jacques-Francois Martin, formerly CEO of vaccine maker Sanofi-Pasteur, CEO of vaccine maker Chiron, and President of the International Federation of the Pharmaceutical Manufacturers’ Association. While at The Vaccine Fund, his salary was paid by a company that says it “has developed particular strength in the vaccine industry and vaccine development.”
    5. The dual role of the CDC undermines the appearance of fairness.
    . There is a perceived, if not real, conflict of interest with the government’s Centers for Disease Control (CDC) heavily promoting vaccines, but also responsible for monitoring adverse events. At least two respected medical journals, the “American Journal of Public Health” and “Pediatrics” have published letters or articles recommending “greater independence in vaccine safety assessments” apart from “the highly successful program to promote immunizations.” In short, the CDC’s bread and butter is achieving high vaccination rates. But that role is in conflict with the agency’s responsibility to fully research and disclose adverse events that could, in theory, bring down vaccination rates.
    6. There is no definitive research proving a link between vaccines and autism or ADD, but there is also no definitive research ruling it out.
    . Something rarely reported is that while there’s no definitive study linking vaccines to autism or ADD, there is also no study definitively disproving a link. And there’s a substantial body of peer-reviewed, published science from places like Columbia, Yale and Northeastern suggesting a link, or pointing to the need for further study.
    . Many credible voices deny a link. But many other credible voices support the idea of a link. One example of the latter is George Wayne Lucier, formerly a senior official at the National Institutes of Health in Environmental Toxicology, an NIH advisor, member of the National Academy of Sciences Committee on Toxicity Testing and a scientific advisor for EPA who concludes “…it is highly probably that use of thimerosal as a preservative has caused developmental disorders, including autism, in some children.” A lengthy Congressional investigation also concluded that the autism epidemic is likely linked to vaccinations.
    7. Those who say autism and ADD are not linked to vaccines do not know what is causing the epidemics.
    . The most frightening part of the autism/ADD epidemics is that if, indeed, they’re unrelated to vaccinations, that our best, brightest public health experts still have no idea what is causing it. Excluding ADD, one out of every 150 American children are now being diagnosed with autism.
    Vaccinations have provided lifesaving miracles in public health. However, it’s undisputed that they are also responsible for many serious adverse events including brain disorders and, rarely, deaths. Trying to maximize the potential benefits of vaccines and minimize the harm shouldn’t be seen as a threat to the nation’s inoculation program, it’s merely a logical step forward.
    One scientist who testified for the plaintiff this week in The Vaccine Court said there’s a way to test children for a hidden hole in their immune make-up that makes them susceptible to bad immune reactions from vaccinations. He said that, ideally, every child should undergo such a test before their first vaccinations. But he also said the test is very expensive and so “not worth it.” Many parents might disagree. If they knew such a test was available, they’d find a way to pay for it. But such information has to be disseminated to the public before a first step can even be considered.
    Mainstream medicine initially said that autism was caused by mothers who weren’t affectionate enough with their children. If that doesn’t teach us that we should always seek further knowledge and not necessarily accept what’s spoon-fed to us by certain experts.then nothing will.

  20. Doctor Sunshine says:

    I would also like to extend my appreciation to Dr. Poling for posting the open letter.

    A general question, though, is whether he himself posted his open letter on the Age of Autism site or whether somebody else cut and pasted it there?

    The gist of Dr. Poling’s letter, in regard to mitochondrial dysfunction and his daughter’s mutation, seems to me that he believes that *something* (presumably vaccination) caused mitochondrial dysfunction, but the mutation found is not the sole cause of her subsequent clinical disease process? Am I reading this right?

    Thimerosal…thimerosal…thimerosal. Sandy Gottstein’s comments are strongly suggestive of the pharmaceutical-government conspiracy…Even though the vaccine product information states that only trace amounts may remain in the final product after processing, the anti-vaccine crowds appear to believe that the product information is false and drug companies are still, presumably intentionally, pumping their product full of thimerosal? Anybody in the anti-vaccine movement take a dose of good old DTaP and independently analyze its thimerosal content? It should be relatively easy for a DAN! doc to accomplish…

    0.5 cc of thimerosal-containing influenza vaccine does not a mercury-poisoned child make, in my general pediatric clinical experience (nor, for that matter do any of the vaccines I’ve recommended to thousands of patients who I then followed through numerous post-vaccination visits, unless the children were masking their autistic features and the parents didn’t feel the need to tell me about their secret diagnoses…)

    I know this claim has been beaten to death, but, has anybody pointing the finger at thimerosal, and this includes Dr. Poling in his comments on thimerosal, mercury, etc., considered the biochemistry of the neurotoxin that is *methylmercury* and the lack of neurotoxicity documented with the *ethylmercury* in thimerosal? Or is it just presumed that mercury in any form or function or homeopathic dose is poisonous to our systems?

    Just some thoughts from a neurodevelopmentally minded general pediatrician on this topic (at least now I have a possible subject for my fellowship research!)

  21. There is evidence that the reduced exposure to thimerosal is not likely to be toxic. Here is a study that shows that infants clear ethylmercury more quickly than adults, so quickly that the mercury from thimerosal would not build up from one vaccine to the next: http://www.theness.com/neurologicablog/index.php?p=185

    We do have a good idea how many vaccines still had thimerosal after 2002. A survey (as I mentioned and which was ignored by later commenters) conducted in 2002 found that only 1.9% of relevant vaccines in doctor’s offices still had thimerosal, and these were soon to expire (Centers for Disease Control and Prevention Advisory Committee on Immunization. 2002. Practice Records of the meeting held on February 20-21, 2002, Atlanta Marriott North Central Hotel.)

    There is no avoiding the fact that the total thimerosal exposure to children was dramatically reduced as of 2002, and this was not followed by any decrease in autism diagnosis. This is incompatible with the claim that the prior increase in thimerosal exposure was responsible for the increase in autism diagnosis rates.

    Also – here is evidence that early signs of autism predate most vaccines: http://www.theness.com/neurologicablog/index.php?p=184

    And here we see a lack of association between pre-natal vaccine and autism: http://www.theness.com/neurologicablog/index.php?p=85

    The comment from jt is little more than an ad-hominem logical fallacy – they’ve been wrong before so they are wrong now. This is irrelevant to the scientific evidence.

  22. Dr. Novella,

    Burbacher et al found that ethylmercury does not clear the brain as fast, which is where it does its damage (after converting to inorganic mercury more readily than does methylmercury). After all, mercury is a neurotoxin.

    And claims that ethylmercury leaves the blood faster may well be misleading and meaningless. As Burbacher said in this WebMD article (http://www.webmd.com/brain/autism/news/20080130/vaccine-mercury-leaves-blood-fast) “Just because it came out of the blood doesn’t mean it is excreted from the body. It could have gone to the brain,” Burbacher tells WebMD. “Although total mercury levels in the blood are lower following thimerosal exposure [than following methyl mercury exposure], mercury in the blood from thimerosal has an easier time getting to the brain than methyl mercury.”

    I also did an analysis of a 2002 Pichichero Lancet study which I called “Garbage In – Less Than All The Garbage Out” in which I dispute the results of that study.(http://www.vaccinationnews.com/Scandals/2003/Jan_17/Scandal51.htm)

    To repeat, given that we don’t know exactly how much mercury it takes to injure susceptible children, saying autism predates most vaccines says nothing since it doesn’t predate DPT. In fact the first cases, perhaps coincidentally, started around when DPT was first introduced. The connection between high intelligence and the early autism might well be at least partly explained by the likelihood that intelligent parents were more likely to get their children vaccinated. If it “only” takes a small amount, i.e., the amount in just one vaccine to trigger autism, the amount in DPT vaccine might well be enough.

    Dr. David Baskin, professor of neurosurgery and anesthersiology at Baylor College of Medicine said essentially the same thing when he testified to Congress that “Thimerosal was placed in vaccines in the late 1930’s and guess what? Three years later, Leo Cantor (sic – Kanner) first described the syndrome of autism. Never, ever been described before in the medical literature. The neurotoxicity of mercury has been very well established in terms of brain injuries since the 1960s, as you’ll see. In 1956 and 1960 there were massive outbreaks of mercury poisoning in Iraq, and the reason this happened was that ethylmercury was used as a fungicide. The grain was treated with this fungicide, the idea being that you could plant this grain; it would grow; the crops would flourish; but I imagine because of poverty a lot of this grain was just taken and made right into bread and people ate it. So they ate these doses of mercury. There were hundreds of cases, both in Iraq, and then there was a similar outbreak in China. A number of these cases just had really severe, horrible brain damage, but what came out of this work, there was a much more mild syndrome, with developmental delays and neurodevelopmental disorders, problems with language, problems with communication. Some of the descriptions of these kids looked just like your videotape. So, pretty early in the 1960s it ws known there was a direct relationship of a dose of mercury (i.e., ethylmercury – my note) received and the severity of the injury. And, as early as the late ’60s, the scientific literature said the fetal and infant brain is clearly more sensitive than the adult brain.” To read the entire testimony go to: http://www.a-champ.org/congressionalreports/GRC12_10_02.pdf

    By the way, the FDA banned thimerosal for topical use in 1982. It doesn’t pass the straight face test to suggest it is toxic for topical use, but benign when injected.

    All the best,

  23. Doctor Sunshine says:

    Ms. Gottstein,

    I sincerely believe that the weight of the scientific evidence has failed to document a correlation of cause and effect between thimerosal-containing vaccines and autistic spectrum disorders, as Dr. Novella very clearly delineated in his subsequent post.

    “the evidence ignored or dismissed by those in charge…”, again, the hint of government conspiracy. Plus, I would think that the amount of research that has been done to assess the possibility that thimerosal-containing vaccines may be linked to the rise in diagnoses of autistic spectrum disorders is an indication that this area has not been ignored, only dismissed by the burden of scientific evidence.

    With the last comment, referring to “propaganda [is] published in Pediatrics which is owned by the American Academy of Pediatrics”, I consider a statement like that to be an insult to hard-working pediatricians nationwide by accusing them of either compliance or ignorance in service of a cover-up scheme conducted by “Big Government” and “Big Pharma”. As has been seen over the course of our shared public health experience with vaccination, when medical concerns are noted with specific vaccines, the recommended schedule is revised to address these issues – the Rotashield vaccine specifically comes to mind. My colleagues would not continue to recommend vaccines if there was clear evidence that thimerosal causes autistic spectrum disorders.

    Back to the original reason for my initial comment, am I correct in my review of Dr. Poling’s letter and his description of his daughter’s mitochondrial condition?

  24. Sandy,

    Sorry I was unlcear – but you should have read the blog entry I linked to. What I meant was that symptoms of autism appear in infants before they receive vaccines. Therefore the timeline does not support vaccines as a cause.

    The argument that we don’t know how much thimerosal is necessary to cause neurotoxicity is not valid. You keep failing to address my primary point – thimerosal exposure was reduced, even if it was not eliminated. If there were a causal relationship between thimerosal and autism than autism rates should also have decreased, and they didn’t. This is especially true since the primary line of evidence being offered was the alleged prior increase in autism when thimerosal exposure increased. The data simply does not fit the mercury-autism hypothesis.

    It is true that blood clearance does not prove body clearance, but the same study did show that mercury showed up in the urine and stool as it was being cleared from the blood, so this suggests that it was being cleared from the body – not just moving to the brain. But this study did not quantify total mercury excretion so it is true that we need a follow up study that looks at total mercury excretion and compares that to blood levels to more definitively determine where the mercury is going.

  25. daedalus2u says:

    The most replicated finding in autism is a larger brain with more neurons. What kind of “neurotoxin” causes a larger brain with more neurons?


    That kind of “neurotoxicity” has never been associated with mercury in any form.

  26. Thank you Dr. Novella for our respectful reply. However, I, too, must respectfully disagree. Your statement that symptoms of autism appear before vaccinations is simply untrue for the vast majority of autistic children. Perhaps you are unaware of regressive autism.

    And while you think I am not addressing your point, you are assuming an absolute linear relationship between dose and response. If trace amounts are all that are needed in some susceptible children, then unless even trace amounts are eliminated, you would still see an increase. Besides, there is still the full amount in the flu vaccines, which the mother might have gotten while pregnant with the child, and the child might have gotten at 6 months as well. However, given that the FDA and CDC don’t even know what the amounts of thimerosal are in current vaccines, and no one really knows how many of the old vaccines are still being used, I’m not sure how it is that you are so certain about all this. This is especially critical given the time lag between the first signs of autism and diagnosis.

    As for the mercury showing up in the stools, if you read my “Garbage In” column, you will see what I think of that analysis. And unless you are comparing those with autism to those without it, the amounts that show up in blood or urine may simply reflect better excretion ability among non-autistics. As has been suggested by some, autistic children seem to lack the ability to excrete thimerosal more than non-autistics do. Underlying mechanisms for this have been proposed and supported by the literature, including glutathione issues.

    Doctor Sunshine, I am sorry that you are offended by my point of view. However, just because rotashield was withdrawn, that doesn’t mean all problematic vaccine issues have been dealt with. One of the most prominent ones in my opinion occurred when polio vaccine was discovered to have a hamster oncogene contaminating it. Rather than recall the vaccines, they were allowed to remain in the market so as to avoid arousing concerns about the vaccine. This was reported in Science, in the article called “The Boat That Never Rocked”. There is now reason to believe that not only may that virus cause cancer in humans, but that it now may be spread among them.

    As for compliance or ignorance in service of a cover-up by hard-working pediatricians, it is my opinion that one can merely be ignorant of the facts without being part of a cover-up.

    For instance, are you aware that many, if not most, vaccine-associated infant deaths reported to VAERS occur within hours or days of vaccination? I did a study of those infant deaths reported in 1998, finding 88 of them, and discovered that around 35% of them occurred within 24 hours and about 55% within 3 days. Add to that the fact that former FDA commissioner Graham once noted that only 1% of serious adverse reactions are reported to the FDA and a vaccine manufacturers estimate (to the IOM) that only 2% are reported in a passive reporting system, which is what VAERS is, these data become even more troubling. Even taking a conservative estimate that the 88 represent 10%, not 1 or 2%, that would mean approximately 8800 infants died, more than half within three days of vaccination. While this is certainly not proof of anything, it is troubling evidence of something seriously wrong going on right under our noses that no one is bothering to properly study. (Go to “Infant Vaccine Deaths – But Who’s Counting? (No news is NOT good news.)” at http://www.vaccinationnews.com/Scandals/Feb_22_02/Scandal5.htm for the entire column.)

    If you have been aware of this fact, but have done nothing about it, I suppose you might be considered to be part of a cover-up, or at least guilty of the “crime of silence”. However, if you have been ignorant of those facts, there would be nothing to cover-up.

  27. daedalus2u says:

    Sandy, If you are talking about the James paper on glutathione, it was done in plasma. Plasma is a completely unimportant tissue compartment for glutathione. Where it is important is inside cells where the level is 3 orders of magnitude higher than in plasma. That is 1000 times higher. If there were a change in cellular levels of glutathione, that might mean something. Plasma levels likely mean nothing.

    There has not been a single study that has shown any problems in mercury excretion. There has been no physiological explanation of how there could be a problem with mercury excretion.

  28. daedalus2u, Unless I misunderstand you, the following is an example of just such a study. If I get the time, I will try and find additional relevants studies:

    1: Int J Toxicol. 2003 Jul-Aug;22(4):277-85.Links
    Reduced levels of mercury in first baby haircuts of autistic children.Holmes AS, Blaxill MF, Haley BE.
    SafeMinds, Cambridge, Massachusetts, USA.

    Reported rates of autism have increased sharply in the United States and the United Kingdom. One possible factor underlying these increases is increased exposure to mercury through thimerosal-containing vaccines, but vaccine exposures need to be evaluated in the context of cumulative exposures during gestation and early infancy. Differential rates of postnatal mercury elimination may explain why similar gestational and infant exposures produce variable neurological effects. First baby haircut samples were obtained from 94 children diagnosed with autism using Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV) criteria and 45 age- and gender-matched controls. Information on diet, dental amalgam fillings, vaccine history, Rho D immunoglobulin administration, and autism symptom severity was collected through a maternal survey questionnaire and clinical observation. Hair mercury levels in the autistic group were 0.47 ppm versus 3.63 ppm in controls, a significant difference. The mothers in the autistic group had significantly higher levels of mercury exposure through Rho D immunoglobulin injections and amalgam fillings than control mothers. Within the autistic group, hair mercury levels varied significantly across mildly, moderately, and severely autistic children, with mean group levels of 0.79, 0.46, and 0.21 ppm, respectively. Hair mercury levels among controls were significantly correlated with the number of the mothers’ amalgam fillings and their fish consumption as well as exposure to mercury through childhood vaccines, correlations that were absent in the autistic group. Hair excretion patterns among autistic infants were significantly reduced relative to control. These data cast doubt on the efficacy of traditional hair analysis as a measure of total mercury exposure in a subset of the population. In light of the biological plausibility of mercury’s role in neurodevelopmental disorders, the present study provides further insight into one possible mechanism by which early mercury exposures could increase the risk of autism.

    PMID: 12933322 [PubMed – indexed for

  29. daedalus2u says:

    Sandy, I am very familiar with the mercury and autism literature, I have a blog post where I have discussed the failed idea of mercury causing autism.

    The first haircut baby hair paper, I think is actually reasonable data which to my mind “drives the stake through the heart of the dead horse that is the mercury causes autism idea” (to mix a few metaphors). The most affected children had the lowest hair mercury levels.


    For those children to have toxic blood levels of mercury while having those levels of hair mercury would require a blood mercury/hair mercury ratio 3 or 4 orders of magnitude different than has ever been observed in any organism. There is no even remotely plausible mechanism that could explain that.

    There is no support in the literature for the idea.

    I suggest that you look at some of the real scientific literature on mercury. A good place to start is the Faroe Islands study where 996 consecutive births out of 1404 born over a 2 year period were tested at birth for mercury in multiple tissue compartments including cord blood and umbilical cord tissue. They did measure hair mercury levels too, and found quite an accurate ratio with no outliers. 747 of these children had cord blood mercury levels above 65 nM/L. I assume that you have seen the DeSoto reanalysis of the Ip et al results? The two highest individuals had blood mercury levels below 60 nM/L and they were discarded as “outliers”. 249 of the Faroese children had cord blood levels above 200 nM/L.

    There was a study that looked at autism on the Faroe Islands. In the 1404 child cohort they found 5 cases, 2 with autism and 3 with Asperger’s. It has not been reported if they were among the 249 children that had cord blood mercury levels above 200 nM/L.

    Go to PubMed and search on Faroe mercury and also on Faroe autism and you will find these papers.

    The studies you cite have been thoroughly debunked.

    Olmsted didn’t do a survey.

    Toxicity in tissue culture depends on the dose the cell absorbs. Mercury partitions into cells where it becomes attached to thiols. A few cells in a large tissue culture volume could easily concentrate mercury 1000 times or more over the concentration used in the media. The cells were not assayed for mercury. It was assumed that cells did not concentrate mercury and so the concentration added to the media was the same as the concentration in the cells. An assumption known to be false.

    The strain of mice that Hornig used are known to be highly disturbed and even cannibalistic.

    If you are referring to the paper that Bradstreet published, I debunk it in my blog. The distribution was highly skewed, with a standard deviation greatly exceeding the mean value (which was the only value reported), disingenuously suggesting it was “significant”, meaning representative and important. We know it was neither. Even in that report many of the autistic children had zero mercury excretion. The “increased mercury excretion” amounted to 3.3 micrograms over 3 days. The amount of mercury one could get by eating a single ounce of canned tuna. There is no conceivable mechanism in physiology by which anyone could have toxic levels of mercury and not show it in any tissue compartment that can be sampled. No mechanism has been suggested, other than some magical “non-excreter” idea, an idea which has no support in data or in theory.

    There is no good science to support the false “mercury causes autism” idea. There is much evidence to suggest it is nonsense.

  30. daedelus2u,

    First, the entire point of the hair/mercury paper was that those children who do not excrete it have the least amount in their hair.

    Second, given the obvious danger in doing brain biopsies on living children, there is little chance that we are going to see what might be definitive evidence that autistic children have more mercury in their brains than non-autistic children, or that chelating mercury removes it from the brain. Because of this we have to look for indirect evidence in children, autopsy dead children (autistic and not), and/or evidence in animals. Citing the amount of mercury in the blood, cord blood or anywhere other than the brain will not be relevant if autistic children do not excrete mercury and it goes to their brains.

    Third, what CAN be done is compare the vaccinated to the never vaccinated. Here is what happened when I suggested this to the CDC and NIH at a Government Reform Committee Hearing on autism: http://www.vaccinationnews.com/Scandals/Sept_27_02/Scandal35.htm

    Doing such studies would not be proof, but they would provide evidence. The fact that they are not being done, and never have, speaks volumes.

    Fourth, there is clinical evidence of children recoving to varying degrees after having mercury chelated from their bodies. I’m sure you dismiss such evidence as anecdotal.

    Fifth, just because you say there is no scientific evidence to support the thimerosal/autism connection, doesn’t make it so. For instance, I just gave you well-known, credible evidence from Dr. Baskin. But I am not going to take the time to introduce any more evidence because you will act as if it doesn’t exist.

    Finally, I am tired of arguing with people who aren’t even willing to say who they really are. At least Dr. Novello does that. So this will be my last communication with you and those who hide behind an alias.

  31. TheProbe says:

    Once again, the anti-vaccination Merchants of Disease, Disability and Death play their nefarious games. One comes in whining about cherry picking, while this is the stock in trade of the Mercury Militia.

    And, then, there is Ms. Gottstein who relies on her own studies and newspaper articles by Olmsted and Kirby. Olmsted claims he visited Amish Country, but never found an austisticchild. He also never visited the Clinic for Special Children. Kirby’s diatribes are so replete with falsehoods and misstatements of facts, that a first year journalism student can pick him apart.

    The bottom line is quite simple, no matter how well researched, no matter how well documented, no matter anything, the Merchants of Disease, Disability and Death will continue their efforts to discredit vaccines.

    Nothing will stop them. Nothing.

  32. daedalus2u says:

    Sandy, not considering my arguments because I use a pseudonym is an ad hominem argument. It says nothing about the merits, the facts or logic of my argument. It says a lot about the weakness of your position that instead of providing facts and logic to counter my arguments you resort to an ad hominem abandonment of communication. I have no illusion that I will be able to convince you. The belief that mercury causes autism was not arrived at with facts and logic, facts and logic are not going to be able to displace that belief in the “true believers”. My purpose in posting here is to provide information, facts and logic to those able and willing to understand and appreciate it and use it in their understanding of the world.

    The assumption of deficits in mercury excretion in the baby hair paper was an ad hoc assumption which was not supported by the data in the paper or in the literature or by anything which is well known about physiology including mercury physiology. It was an ad hoc assumption with no basis other than in the imagination of the authors.

    When mercury is not found in the hair, the ordinary inference is that mercury levels in every other tissue compartment reflect the normal partitioning between different tissue compartments that is similar to what has been observed in every other study there has ever been done on every organism that has ever been studied. It is an extraordinary claim that in a subset of children there is a 3 or 4 order of magnitude difference in partitioning of mercury between different tissue compartments than what has always been observed. The authors don’t even provide ordinary evidence for their claim or even any evidence at all. They simply assume it.

    You are correct; it would be unethical to take brain biopsies of living humans to determine their mercury level. That the mercury quacks have not stooped that low is only slightly reassuring to me. There have been test of mercury in brain tissue of autistic individuals postmortem, and elevations that indicate physiologically significant excess mercury have not been found in any case. There is no tissue compartment that can be measured that has elevated and toxic levels of mercury in people with autism. There is nothing magical about the brain or the blood brain barrier that prevents mercury from entering or leaving it.

    I don’t dismiss clinical evidence as purely anecdotal, however there has been no such evidence published in the literature regarding resolution of autism symptoms following chelation. There is abundant evidence for the resolution of symptoms of mercury poisoning following chelation. The placebo effect is quite strong in autism, and without proper blinding it is very easy for clinicians to be mistaken. The secretin trials showed that proper blinding is necessary. There has not been a single published trial of chelation improving autism symptoms. Chelation may work, but there is no evidence that it does. There is no physiological mechanism which would suggest that it does. Nothing that is well known about autism or mercury physiology suggests that the two are causally related.

    What I call “scientific evidence” is evidence that has been published in the scientific literature, which I have analyzed and determined to be sufficiently consistent with the rest of the scientific literature that I consider it to be reliable. One cannot “cherry pick” the scientific literature, it needs to be looked at in total. One, ten, or even 50 studies could be in error, the authors may be mistaken, they may have committed fraud. If those studies are incompatible with 10x or 50x more papers in the literature, one needs to be very cautious in how one interprets them. Sometimes the data is reliable even when the conclusions are not. If a paper is consistent with 500 other papers by many different authors it is very likely consistent because all of the papers are describing the same reality. If a paper is inconsistent with 500 other papers it is likely not reliable.

    You can prove me wrong by simply citing reliable information in the scientific literature. I have looked very carefully at the scientific literature and have been unable to find anything that supports the “mercury causes autism” idea and much that proves it wrong. My conclusion is that is because it is a wrong idea that is not consistent with reality. I am always open to more data and new data, but rehashing the old flawed work that has been debunked so many times isn’t useful.

  33. Please share the tests post-mortem on brain tissue of autistics as I did a search and found not one study using the following search parameters:
    (autis*) and (((thimerosal) or (( mercury )or( ethylmercury )or( methylmercury ))) and (autops*))

  34. Also, I’m curious why, in light of the following study, you think that autism is caused by inadequate amounts of nitric oxide:

    1: Biol Psychiatry. 2004 Feb 15;55(4):434-7. Links
    High nitric oxide production in autistic disorder: a possible role for interferon-gamma.Sweeten TL, Posey DJ, Shankar S, McDougle CJ.
    Department of Psychiatry, Indiana University School of Medicine, 1111 W. 10th Street, Indianapolis, IN 46202-4800, USA.

    BACKGROUND: Neuroimmune regulation abnormalities have been implicated in the pathophysiology of autistic disorder. Nitric oxide (NO) is involved in immune reactivity and is known to affect brain neurodevelopmental processes. Recent evidence indicates that NO, and cytokines involved in NO production, may be high in children with autism. The purpose of this study was to verify that plasma NO is high in children with autism and determine whether this elevation is related to plasma levels of cytokines involved in NO production. METHODS: The metabolites of NO, nitrite, and nitrate (NOx), along with the cytokines interferon-gamma (IFN-gamma), tumor necrosis factor-alpha, and interleukin-1beta, were measured in plasma of 29 children with autism (mean age +/- SD = 6.1 +/- 2.8 years) and 27 age- and gender-matched healthy comparison subjects using commercially available assay kits. RESULTS: Plasma levels of NOx were significantly higher in the autistic subjects (p =.006); plasma levels of the cytokines did not differ between groups. NOx and IFN-gamma levels were positively correlated in the autistic subjects (r =.51; p =.005). CONCLUSIONS: These results confirm that plasma NO is high in some children with autism and suggest that this elevation may be related to IFN-gamma activity.

    PMID: 14960298 [PubMed – indexed for MEDLINE]

  35. daedalus2u says:

    Sandy, that study highlights one of the major misunderstandings of NO physiology. NOx in plasma is the terminal metabolite of NO. Actual NO concentrations are on the order of nM/L. The NOx levels they measured in this study are 3-4 orders of magnitude higher. NOx levels represent the production rate of NO, not the concentration of NO. The concentration and the production rate are not necessarily coupled.

    Measuring the NOx level and trying to determine the NO concentration would be like measuring the CO2 concentration and trying to infer the O2 level. It is simply a wrong approach. Many people do it, but it is still wrong. It is data, and it tells us something, but it does not tell us anything at all about NO concentrations. It is more a measure of NO production rate because NOx is cleared from the circulation by the kidneys and other less well characterized pathways.

    In this paper they measured NOx levels of 50 microM/L in ASDs, and 40 microM/L in controls. The actual NO level is less than 10 nM/L. We know that because at 10 nM/L there is systemic vasodilation and the individual is in shock due to systemic hypotension. The only way to achieve levels such as that are via septic shock. During sepsis, the NOx levels can easily go to a few hundred microM/L.

  36. Thank you for the explanation. One of the questions that begs to be asked is whether or not ethylmercury induces oxidative stress. Here is a study which alleges that it may well do so:

    1: Neuro Endocrinol Lett. 2005 Oct;26(5):439-46.Links
    Mercury and autism: accelerating evidence?Mutter J, Naumann J, Schneider R, Walach H, Haley B.
    Institute for Environmental Medicine and Hospital Epidemiology, University Hospital Freiburg, Germany. joachim.mutter@uniklinik-freiburg.de

    The causes of autism and neurodevelopmental disorders are unknown. Genetic and environmental risk factors seem to be involved. Because of an observed increase in autism in the last decades, which parallels cumulative mercury exposure, it was proposed that autism may be in part caused by mercury. We review the evidence for this proposal. Several epidemiological studies failed to find a correlation between mercury exposure through thimerosal, a preservative used in vaccines, and the risk of autism. Recently, it was found that autistic children had a higher mercury exposure during pregnancy due to maternal dental amalgam and thimerosal-containing immunoglobulin shots. It was hypothesized that children with autism have a decreased detoxification capacity due to genetic polymorphism. In vitro, mercury and thimerosal in levels found several days after vaccination inhibit methionine synthetase (MS) by 50%. Normal function of MS is crucial in biochemical steps necessary for brain development, attention and production of glutathione, an important antioxidative and detoxifying agent. Repetitive doses of thimerosal leads to neurobehavioral deteriorations in autoimmune susceptible mice, increased oxidative stress and decreased intracellular levels of glutathione in vitro. Subsequently, autistic children have significantly decreased level of reduced glutathione. Promising treatments of autism involve detoxification of mercury, and supplementation of deficient metabolites.

    PMID: 16264412 [PubMed – indexed for MEDLINE]

  37. You seem to be assuming that ingesting the higher amount in teething powder is more dangerous than a considerably smaller amount that is injected. However, injection of a substance may or may not require the same amount of a substance that is ingested to cause harm. That notion should be tested, not assumed. To validly test that you would have to give some children the normal amount of calomel in teething powder, inject in other groups varying amounts of different kinds of mercury and compare the results. I also don’t think you can assume that mercurous chloride is identical in its effects to ethylmercury or other forms. That, too, needs to be tested.

    Let me repeat this, injection of a substance may or may not require the same amount of a substance that is ingested to cause harm.

    It was concluded in “The puzzle of pink disease”, which you so kindly shared with us, “It was not a question of dosage – that is, straightforward poisoning – since some children who had received repeated doses remained unaffected…No explanation has ever been advanced for this curious fact…” So, too, it may not be a matter of dosage with ethylmercury and autism.

    As one fairly recent (1997) writer on pink disease said, “The resistance to the evidence of mercury poisoning is typical of resistance to new medical knowledge and declined only when the opponents and sceptics grew old and disappeared from the scene.” (From “The rise and fall of pink disease.”) Seems fairly similar to what is going on today.

    I think there is ONE thing we can agree on, though. You consider yourself to be an expert on just about everything related to autism.


  38. daedalus2u says:

    Interesting that you say “That notion should be tested, not assumed.” What part of the “mercury causes autism” idea has ever been tested? No part of it at all. The “non-excreter” idea has never been tested, it is simply assumed. Simply because mercury can’t be measured in any tissue compartment, it is assumed that the mercury “must be” in a form and in a tissue compartment where it is completely invisible to all modern methods of detection. To me the more plausible explanation is that it isn’t there at all. The McGinnis paper on mercury levels in autistic brains shows the level is no different than in non-autists. Now that the notion that there are toxic levels of mercury in autistic brains has been tested, it is wrong to assume it is different than what the data shows.

    I am sure you are familiar with Burbacher’s study on the difference between oral methyl mercury and injected thimerosal. The oral methyl mercury had a much larger effect on blood mercury levels and on brain mercury levels than did injected thimerosal. Both blood and brain mercury levels were considerably higher with oral methyl mercury than with the same amount of mercury injected as thimerosal. His work showed that oral methyl mercury is better absorbed and has a longer lifetime in the body than does injected thimerosal. Methyl mercury is the form of mercury in fish. A single can of tuna fish has more mercury than a single vaccination, and the mercury in fish (methyl mercury) is better absorbed orally than is injected thimerosal. We don’t need to assume anything, Burbacher tested that.

    Children with pink disease did have mercury poisoning. Children with mercury poisoning in the modern era have had elevated mercury levels. When those mercury levels were reduced with chelation their pink disease disappeared. The levels of mercury in children with pink disease are many thousands of times higher than occurs due to vaccination. That some people are susceptible to 50 mg of mercury and some people are resistant to 150 mg in no way suggests that some people are sensitive to 15 micrograms. As you say, “That notion should be tested, not assumed.” The pharmacological effects of giving 65 mg of calomel to infants orally cannot be tested in humans because it would be unethical. There is no conceivable benefit and there is likely harm.

    I agree with you that there are some similarities with what is going on today. Mercury was put into teething powders and heavily marketed with zero basis in physiology and with zero testing. Many children were injured as a result. Similarly many of the quack biomedical “treatments” for autism are heavily marketed with zero basis in physiology and with zero testing. Many children have been injured as a result. Secretin, chelation, hyperbaric oxygen, endocrine disrupters, even homeopathic thimerosal. Children have died from being chelated. A few episodes of chelation is known to cause neurological damage all by itself. What does years of chelation do?

    Do any of these “treatments” actually accomplish anything other than to enrich the quacks pushing them? As you say “That notion should be tested, not assumed.”

    I only consider myself an “expert” in areas where I have read a great deal of reliable information and have thought deeply about the subjects. In autism that includes physiology, particularly physiology related to NO and mercury. My expertise does not encompass behavioral treatments. I am very much aware of the limits of my knowledge and am always trying to expand them, but only with reliable information. To quote Clint Eastwood, “a man should know his limits”. To me, that is the mark of every “professional”, a person who knows their expertise and doesn’t attempt to practice outside it. I am not a doctor, and am not pretending to be one. I am not attempting to practice medicine. The reason I am posting here is to attempt to educate people as to the importance of NO physiology in a number of disorders, including ASDs. I am trying to mitigate the harm being done by the quacks set on destroying the vaccine industry.

  39. In my opinion you are taking what you like from studies and ignoring the rest. For instance, as I noted earlier re: Burbacher, he found that there were special, serious problems with ethylmercury. But I’m not going to keep repeating myself here.

    And of course the studies I mentioned would be unethical. But because they are, we don’t have a full picture of things.

    I would be perfectly happy to find that all the mercury being given to these children is harmless. You are convinced that all the studies prove it so; I am not.

    Also I simply don’t understand how you can say there have been no studies showing chelation works, yet state that chelation worked with pink disease.

    I also haven’t gotten a chance to review the some 700 articles listed in medline concerning chelation and mercury. What I do know is that the only study listed at http://www.clinicaltrials.gov which deals with chelation leaves out those who have toxic levels of mercury. While there may be perfectly good reasons in terms of the safety of those children to exclude them, the fact is that if such a study is used to suggest that chelation doesn’t work, it would be a dishonest use of the results.

    And lest you think I am being cavalier about the dangers of chelation, that is far from the case. But it is important to distinguish properly conducted chelation from that which is not. For instance, I seem to recall two deaths that got a good deal of attention, but it turned out that the wrong substance was used to chelate. It is also important to recognize that nothing is without risk, that these children are very sick and suffering considerably, and that compared to treatment by regular doctors, which even JAMA apparently admits is the third leading cause of death, (http://www.vaccinationnews.com/DailyNews/May2001/DocsThirdCauseDeath.htm – sorry but I don’t have the original article), as it has been practiced, chelation has been relatively benign in its outcome, at least so far.

  40. As this conversation isn’t going anywhere and is taking up too much of my time, I’m done. Think what you like.

  41. daedalus2u says:

    Sandy, sorry to be so harsh and beat your faux argments to shreds, but real children are being harmed by the quackery that you and others like you are pushing. If you succeed in destroying the vaccine industry even more children will be harmed.

    You need to spend more time understanding the data in the primary literature not the cherry picked sound bites that the breath-takingly incompetent “experts” have pulled out of you know where.

  42. kim spencer says:

    Dr. Novella,

    As the parent of a child who has been diagnosed with autism and mercury toxicity, I have quick questions for you. I found this quote of yours,

    “I’m always open to new evidence, if they can show it works. I
    think the burden on any practitioner is to show it’s safe and effective
    before it’s used.”

    So here are my questions:
    Where’s the safety data on thimerosal? Where’s the safety data on vaccines used in combination? Especially for infants, like for example, one at birth, 4 at 2 months, 4 at 4 months and 3 at 6 months?

  43. Kim,

    I agree that the vaccine schedule was increased without first conducting additional safety studies on the cumulative effect of the increase, specifically the increased total dose of thimerosal. Approval was based upon data that individual vaccine combinations (like MMR) were safe. Also, vaccine safety has been monitored by various methods, specifically the vaccine safety datalink.

    This is certainly an important point going forward, and it is reasonable to require safety studies on the entire vaccine schedule not just individual vaccines.

    However, this is a separate question from whether or not vaccines, as they have been given, can be linked to autism or other neurological disorders. The data here is very clear – there is no association between vaccination and risk of autism. It is likely (although this needs further research) that children excrete ethyl mercury more quickly than adults, and the safety buffer that was in place was more than sufficient to accommodate the increased vaccine schedule.

    So now we do have the data in retrospect.

  44. daedalus2u says:

    If I might add, the only recognized method for diagnosing mercury toxicity is analysis of tissue and/or fluid specimens for mercury and finding levels in what is known to be a toxic range. Known exposure to known toxic levels is a sufficient basis to start treatment even without symptoms of mercury poisoning. However there should be testing for mercury to determine when treatment can be ended. Testing and basing treatment endpoint on actual mercury levels is important and necessary to avoid both inadequate treatment, and excess treatment both of which have adverse effects.

    For many cases of known mercury poisoning there is a very long lag between exposure and development of symptoms of mercury toxicity. “Symptoms” of mercury toxicity alone are usually not an adequate basis for starting or ending treatment. There is the very tragic case of a woman, a heavy metals researcher, exposed to a lethal dose of dimethyl mercury who had no symptoms for 5 months while she had a lethal body burden of mercury. Hair samples analyzed in retrospect showed enormous mercury levels, over 1000 ppm.


    Symptoms that mimic mercury poisoning in the absence of mercury must be caused by something else because toxic levels of mercury are not present. Mercury is easy to measure in relatively non-invasive specimens. The tests are cheap and highly reliable.

  45. kim spencer says:

    Oh, Rita, you DID miss something. He said, “the vaccine schedule was increased without first conducting additional safety studies on the cumulative effect of the increase, specifically the increased total dose of thimerosal.”
    Lucky for Dr. Novella that despite any safety data, which he deems to be the “burden” of the medical community, all vaccines with any current ingredients and in any combination do not cause any problems that may end up in autistic like symptoms or we’d really have a problem here! Sheww! The medical community really got off easy (and again, LUCKY) on that one, huh? It’s an open-shut case for sure!

  46. kim spencer says:

    Funny, I never heard that a person is wrong because bloggers say so. That’s hilarious and no leg to stand on in any argument. And, sorry, daedalus, it’s clear that you are not going to hear ANYTHING anyone else says on this topic, and that’s a huge reason why there’s a debate here. Too many people claiming all-knowing medical proficiency in every area refuse to acknowledge when someone has a good point. Like mine point I’ve made here, you blow it off, you refuse to see there’s reasons why a parent who has an autistic child who regressed after vaccines, has been shown to be mercury toxic and has a mess of an immune system and when that parent repairs those issues, “features of autism spectrum disorder” (those same “features” that add up in the DSM-V to be a diagnosis for my son and for Hannah, btw) DISAPPEAR.
    The law can be interpreted in many ways. But here’s what the vaccine court document says,
    “In sum, DVIC has concluded that the facts of this case meet the statutory criteria for demonstrating that the vaccinations CHILD received on July 19, 2000, significantly aggravated an underlying mitochondrial disorder, which predisposed her to deficits in cellular energy metabolism, and manifested as a regressive encephalopathy with features of autism spectrum disorder. Therefore, respondent recommends that compensation be awarded to petitioners in accordance with 42 U.S.C. ยง 300aa-11(c)(1)(C)(ii).”

    Your interpretation of this passage is just a mess.

    And one more point. The stance that
    “there is no decline in autism rates while thimerosal has been virtually removed from childhood vaccines” is just not the whole truth. Not scientific at all. It implies that no child is exposed to thimerosal from vaccines and hasn’t been for years. In realilty, four shots in one day, each with a “trace” amount isn’t “trace” anymore.
    Mandated flu shots for pregnant and 6 months to 5 years adds up to substantial exposure to thimerosal.

  47. daedalus2u says:

    Actually I listen to what everyone says, then I evaluate it using what other people have said and what I can reason out. I have done no original research on mercury, I have only read the research that other people have done. That includes both what real scientists have done and published in the literature as well as what the quacks have done.

    It takes a special kind of hubris for someone with no training or background in science and no understanding of scientific principles to reject science that is well understood and well documented in the literature. Particularly to reject that science without even knowing what it is.

    The emperor had no clothes. That a child said it doesn’t reflect the child’s superior wisdom, it reflects that the child didn’t self-sensor to appease those in power. The child didn’t go along to get along. The child didn’t pretend to preserve her ego. The child didn’t pretend so that her peers wouldn’t think she was foolish. The child didn’t pretend because all her friends were pretending too. The child didn’t pretend because she didn’t want to admit that she had been duped by quacks who had defrauded her.

    The emperor did pretend. Pretending he was “wise” was more important than accepting the reality that he had been duped. He pretended because he didn’t want to admit that he had been duped and swindled by people who had massaged his ego. Duped by people who had appealed to his “special wisdom” as emperor. Duped by quacks who had appealed to his foolishness and who had shown him to be an ignorant fool. Just the way the quacks appeal to the “special wisdom” of parents. The parents of the child pretended the emperor had clothes too. The “special wisdom” of parents didn’t work for them either.

    Whether a person is wrong or not is not determined by public opinion or by who says it. Bloggers are not the final arbiter of truth. Neither are politicians, lawyers, TV hosts or journalists. Neither are parents no matter how much they believe the lies they have been told to recite.

    People interested in actually finding the truth will go to reliable information sources to find that truth out. Many scientific bloggers link to the peer review scientific literature. Don’t believe what the bloggers say, go read the primary literature yourself. Don’t believe the primary literature? Go do the studies yourself. Making stuff up doesn’t cut it. Listening to people who make stuff up doesn’t cut it either.

    To show that a child is “mercury toxic”, you have to show there are toxic levels of mercury present. That is toxic with the “real” kind of mercury, the kind that shows up on an actual chemical analysis. So far there has been no report in the literature of any children with autism actually having any “toxic” levels of mercury. Every report I have seen shows very modest non-toxic levels. Levels a small fraction of levels that have been clearly demonstrated to not cause autism.

    I know that mercury toxicity can’t be reliably diagnosed by symptoms. It takes measurement. I linked to the case of a woman who received a lethal dose of mercury, and carried around a lethal body burden for 5 months with no symptoms.

    Since you are claiming expertise in knowing when a child is mercury toxic, how much mercury does it take to make a child “mercury toxic”?

    When you say “substantial”, what do you mean? More than a single can of tuna fish? More than 2 cans? More than 10 cans?

    Albacore canned tuna averages 0.353 ppm mercury.


    A 6 ounce can then has 60 micrograms of mercury. Is 60 micrograms of mercury in tuna “substantial”? Is 50,000 micrograms of mercurous chloride (calomel) “substantial”? Millions of children were given that much in teething powders. Where are the studies showing that 50,000 micrograms of calomel is not substantial but 10 micrograms of thimerosal is?

  48. kim spencer says:

    You are extremely offensive, daedalus2u. I will walk away, this is not a productive conversation.
    You say, “Neither are parents no matter how much they believe the lies they have been told to recite.”
    Years ago, early in our journey into autism, our hometown neurologist said to me, “it’s not the mercury, but it’s something ‘you girls’ did while pregnant, like drinking Coke or something.” (gosh, isn’t that genius!?)
    I learned right then and there that if anyone was going to help my son it would be me. A lowly old dumb mom with apparently nothing more than parroting skills in your eyes.
    Well, 4.5 years later, my child is better. I got NO answers from the medical community (in the beginning), so I found them on my own. I can read the science, and I have everyday for all this time. I could sit here and list all the science that matches my child’s situation, but I won’t waste my time. My son has been diagnosed mercury toxic through porphyrin testing.

    Dr. Novella,
    Your blog is not a place for open discourse.

    Signing off for good,

  49. daedalus2u says:

    Excess porphyrins are not diagnostic for mercury poisoning. Only toxic levels of mercury are diagnostic.

    When the medical community doesn’t know the answer, they don’t make stuff up.

    When quacks don’t know the answer they do make stuff up.

  50. Dr Aust says:


    Having read through the above, notably Dr Poling’s letter, and a ton of other stuff, still not clear what is the consensus view – or at least your view as a neurologist – about whether kids with known mitochondrial problems ought to be vaccinated as per normal? Or maybe if there are neurodevelopmental paediatrics people reading this who have a view? Reason is that someone asked me this on another thread and I wasn’t sure what to say.

    I was looking around for any existing guidelines and the most relevant part of the standard UK family doctor advice (as e.g. here is that:

    “The following are not contraindications to vaccination, but folklore has had it in the past that they were:”

    * previous history of infection
    * stable neurological condition

    (+ various other things not relevant here)

    Would “stable neurological condition” here in effect include a mito disorder? Not vaccinating leaves the child non-covered for vaccine-preventable diseases – with the possibility that any infections will be worse than normal because of the mito problems – so I was sort of assuming the advice would still be to vaccinate. From a careful read of Dr Poling’s comment above I gathered he was taking a “vaccinate but with extra care” line.

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