February 19, 2013

Scandal: CT Vet Thinks Outside the Box

John Robb holds a picket sign outside PetSmart in Stamford on Friday, January 25, 2013. Robb lost his franchise license from the Banfield Veterinary Clinic inside PetSmart because the company claimed he wasn't properly vaccinating pets. Robb, however, said he is protecting small pets that shouldn't receive the full doses to avoid over-vaccination. Photo: Lindsay Perry

 Such a scandal!

An article in the Stamford Advocate reports that Dr. John Robb, a local veterinarian, has lost his Banfield Hospital franchise license, and may lose his veterinary license, because he gave half doses of vaccines to dogs and cats in his practice.
A vaccination scandal that ousted a well-liked veterinarian from his West Avenue pet hospital inside PetSmart is now threatening to strip the experienced animal doctor of his license to practice in the state.

An ardent advocate for pets at his practice, Dr. John Robb says he will fight the state to retain his license even though he readily admits to giving thousands of dogs and cats smaller vaccination doses than recommended by vaccine manufactures used to ward off a host of diseases, including rabies.

As a result, Banfield Pet Hospital -- the Portland, Ore.-based corporation from which Robb purchased his hospital franchise when PetSmart was built a little over four years ago -- has sent letters to more than 5,000 of his clients telling them their pets have not been properly vaccinated and encouraging them to bring their pets in for boosters, a company official said.
Given there is no off-label use of animal vaccines, what crime has he committed: independent thinking?

If one asks a veterinarian who insists it's safe to vaccinate family pets every year despite research that shows that the more jabs, the greater likelihood of adverse reactions, he'll tell you he can vaccinate as often as he damn well likes.

That's what "no off label use" means.

But Dr. Robb broke with precedent. He did not over-vaccinate. He simply individualized vaccination to the age, weight, health condition and proximity to exposure of his patients. 

Sounds like practicing veterinary medicine to me. 

I've written extensively about how the immune system works to ward off infectious agents. At the tail end of the process, the body develops a memory for any antigen that has caused illness. Vaccines are devised to trigger this process, but the question for concerned pet owners is whether less biologic agent is equally protective as more.

Chart courtesy of Nobel Price Series on the Immune System

The Memory Cells are the second cell type produced by the division of B cells. These cells have a prolonged life span and can thereby "remember" specific intruders. T cells can also produce memory cells with an even longer life span than B memory cells. The second time an intruder tries to invade the body, B and T memory cells help the immune system to activate much faster. The invaders are wiped out before the infected human feels any symptoms. The body has achieved immunity against the invader.
I'm going out on a limb here, and I could be wrong, but it seems to me that it makes no difference to the body's immune system whether you stimulate memory cells with a little or a lot of antigen as long as it triggers the immune system into action. Like you can't be a little bit pregnant.

Nor would you need to jab this animal again and again with the same vaccine to ensure sufficient memory for a particular antigen. There is simply no scientific basis for redundant vaccination. It does not boost memory cells. Period. The end.

Is there any well-researched reason not to reduce the dosage size according to the body weight of a dog or cat? After all, the adult dosage of all conventional drugs and most vaccines is cut in half for children. Wouldn't it be sensible to cut the vaccine dosage in half for animals under 25 pounds?

As far as I know at this point, manufacturers have never tested a reduced dosage of rabies or other vaccine for safety and efficacy in very small or very large dogs, but only on "average" dogs which I suspect is a beagle weighing from 20 to 25 pounds. 

Which is perhaps why a greater percentage of small dogs suffer vaccine reactions. Here’s a detailed explanation from a 2005 study on this which appeared in Journal of American Veterinary Medical Association (JAVMA:)
The risk of a VAAE (vaccine-associated adverse events) in this study population was inversely related to a dog’s weight. This weight-response relationship was previously suggested by results of a [2002] study in which dogs of toy breeds had significantly more suspected VAAEs than other dogs, although body weight was not evaluated. The manufacturers’ recommended dose for all vaccines administered in our study was 1 mL regardless of body weight, and all vaccines were from single-dose vials. Vaccines, in contrast to virtually all veterinary pharmaceuticals, are prescribed on a 1-dose-fits-all basis, rather than by body weight. Prelicensing clinical trials investigate the safety of vaccines with doses in excess of label directions but only in a limited number of dogs. The results of this study suggest that trials in dogs that weigh > 10 kg underestimate the expected VAAE rate in smaller dogs.

Prelicensing clinical trials also investigate the safety of vaccines in several hundred dogs at multiple hospital locations, but specific breeds may be under- or overrepresented. Mature weights of dogs of different breeds may vary by 5 to 10 times and occasionally by > 50 times. Therefore, a 1-mL vaccine dose results in a ratio of vaccine volume received per kilogram of body weight that can vary widely.
Ultimately, in this retrospective study evaluating 3.5 million full vaccine doses administered to 1.2 million dogs, 38.2 adverse vaccine reactions were observed for every 10,000 dogs. Which is not a big number of vaccine reactions. What was surprising, however, were the following observations:
The VAAE rate decreased significantly as body weight increased. Risk was 27% to 38% greater for neutered versus sexually intact dogs and 35% to 64% greater for dogs approximately 1 to 3 years old versus 2 to 9 months old. The risk of a VAAE significantly increased as the number of vaccine doses administered per office visit increased; each additional vaccine significantly increased risk of an adverse event by 27% in dogs ≤ 10 kg (22 lb) and 12% in dogs > 10 kg.

This study confirms that the injection of multiple vaccines at one time is is more likely to produce adverse vaccine events. Moreover, it confirms and quantifies a previous study’s finding on the higher risks in smaller dogs. Further, these adverse events occur more often based on age, i.e, the risk of reaction is greater for dogs from one to three years old than for puppies from two to nine months old. Dogs that have been spayed and neutered are at the greatest risk of adverse reactions.

So given the paucity of research on the safety and efficacy of a reduced dosage of vaccines and the proven likelihood of adverse reactions, I'd say John Robb, DVM is a bloody hero to pet owners. Yet the state veterinary association, state public health veterinarian and others want to strip him of his license.

For what? Thinking outside the box?

I'll keep you posted as this case develops.


yakwool said...
This comment has been removed by a blog administrator.
yakwool said...

What a well written entry. It's amazing how compelling the truth can be when it is presented to succinctly. As a vet student who is becomingly increasingly cynical about how preventive medicine is tackled in companion animal practice, it's glad to see I'm not alone in questioning the dogma. Having said that, seeing that people are prosecuted for this is pretty disheartening.

Surely they won't take his veterinary license away ... right? Is this man never going to work again in his life? Since when were we so uncomfortable with off label medicine?

And how do these malpractice trials work, anyway? Can you defend yourself with evidence based medicine or will the judge / jury rely on expert testimony? If the latter is the case, I fear for any vet who dares to speak ill of Hills. The nutritionists would have a field day.

Pamela Picard said...

A lot of good questions. I have no answers other than the statements Dr. Robb made at his blog. www dot protectthepets dot com.

This began because a business relationship went sour when Mars took ownership of the Banfield clinics and began to revoke charters. Apparently, he wasn't the only veterinarian terminated.

When Robb refused to accept pennies on the dollar for a $2 million business he built, they pulled out the bazookas, mainly alleging that he was practicing bad medicine by giving half doses of vaccine.

He admits he gave half doses; but he did not believe he was doing anything wrong.

I suspect he won't be making public statements until after his hearing before the State Board.

Note, hearing, not trial.

I don't know how it will resolve with the state veterinary board.

There is no "off label" use of rabies. There is no science to support annual re-vaccination of parvo, distemper and hepatitis. There's also no science to support the dosage. According to Dr. Jean Dodds, a prominent vaccinologist, administration of vaccine and dosage is up to the veterinarian's discretion.

But the veterinary community is notoriously sensitive to bad publicity and protective of its vaccine policies regardless how damaging they may be.

I have no idea who will judge in a civil suit what is / is not bad vaccine policy.

I do think it could be an interesting case. Does a corporate owner have the right to dictate vaccine policy as part of a licensing agreement?

In any case, I have very few facts aside from those that Dr. Robb stated on his blog and what I have learned from discussion with other veterinarians.