On September 24, 2019 Israel’s Association of Public Health Physicians criticized Prof. Yehuda Shoenfeld’s “severe lapse of judgment” in publishing a book review of an anti-vaccine pamphlet by two non-experts, and called for his resignation as editor-in-chief of the prestigious Israeli (Hebrew) medical journal Harefuah.
Justified as the criticism was, the Association did not go far enough. For years, Dr. Yehuda Shoenfeld has used his considerable influence to support the anti-vaccine cause. His publications on vaccines and his behavior show his commitment to spreading and promoting anti-vaccine claims. He should not be teaching students on vaccines issues, nor should he be given additional positions of scientific authority, like a place on the Israeli Academy of Sciences and Humanities.
Dr. Yehuda Shoenfeld has a long and distinguished career in Israel, with multiple prominent appointments and extensive professional connections. He serves as editor-in-chief for both Harefua and the Israeli Medical Association Journal, is editor-in-chief of other journals, and serves on the editorial board of many more.
Dr. Shoenfeld heads the Zabludowicz Center for Autoimmune Diseases at Sheba, Tel-Hashomer. He had other affiliations with Sheba and is a professor emeritus in the Faculty of Medicine in Tel Aviv University.
He is extensively published, and known for his work on autoimmune conditions. He is on the editorial boards of many medical journals.
Harefua is the professional publication of the Israeli Medical Association, the face of Israeli medicine, published since 1924. In its September volume, the journal published a review of a Hebrew-language pamphlet called “Turtles all the Way Down – Vaccines, Science and Myths.”The pamphlet is anonymously published, but claimed and promoted by Israeli anti-vaccine activists, and is full of anti-vaccine myths. The glowing review of the pamphlet, written by two criminologists with no relevant background, endorsed the anti-vaccine content. Even without the anti-vaccine content, publishing a review of an anonymous pamphlet by non-expert is unusual – and the anonymity makes it challenging to track whether there were any links between the authors and the book creators. The review was not brought to the attention of subject-matter experts on the editorial board of Harefua, and it’s unclear what, if any, peer review or other quality control it went through.
On September 22, 2019 Dr. Shmuel Rishpon, an infectious disease experts on the editorial board, wrote a letter criticizing the publication, and calling out the procedure that did not involve consulting with board members.
On September 24, 2019, Israel’s Association of Public Health Physicians published this strong condemnation:
Translated, the post reads:
“The Israeli Association of Public Health Physicians condemns the severe lapse of judgment of Dr. Yehuda Shoenfeld, editor-in-chief, demonstrated in the recent skewed publication in Harefua.
“The Editor-in-Chief failed in his duty and acted unethically by allowing criminologists who openly admit they have no knowledge related to vaccines to write a biased and false review of a pseudo-scientific book written by anonymous authors and which directly endangers public health in Israel.
“The Editor-in-Chief acted without involving editorial board members with relevant professional expertise, like Dr. Shmuel Rishpon, an expert in public health and the chair of the advisory committee on infectious diseases and vaccines.
“We call for an urgent and thorough internal inspection of the journal Harefua, and immediate dismissal of Prof. Shoenfeld due to his reprehensible behavior, his acting as the standard-bearer for the anti-vaccine activists, and not for the first time.
“This behavior is reminiscent of no less than the faking of the study regarding MMR by the disgraced British doctor, Andrew Wakefield, about 20 years ago….” (there is more, but it is less crucial to this post).”
These are strong words, and it is important to understand the background to them. Dr. Shoenfeld has, for years, used his influence to promote unfounded claims that can wrongly scare people from vaccinating their children, putting those children and others at risk. He has put his considerable influence behind anti-vaccine efforts in several contexts. Today, he can be fairly described as an anti-vaccine activist, and as a producer of flawed science – disinformation – in the service of the anti-vaccine cause.
Shoenfeld’s service to the anti-vaccine movement appears centered on his belief – against the data – that vaccines cause a wide range of autoimmune conditions.
Autoimmunity Syndrome Induced by Adjuvants (ASIA):
Since at least 2011, Dr. Shoenfeld and collaborators claimed to have discovered a new syndrome caused by vaccines – Autoimmunity Syndrome Induced by Adjuvants, or ASIA. As of 2017, Shoenfeld and collaborators have published 95 articles on ASIA. ASIA has been used as a theory behind vaccine harms in multiple vaccine court cases (for example here and here).
ASIA, however, as set out by Dr. David Gorski, is problematic in three ways. First, it is so ill-defined that it can encompass any tiredness or any problem after a vaccine, and hence not well defined as a syndrome. Second, there is little to no good data behind it, and abundant data against it in several contexts. Third, several papers in support of the syndrome have internal and external problems.
Dr. Shoenfeld explained that ASIA is:
… a new syndrome, which refers to autoimmune syndromes induced by adjuvants. It includes several conditions that are not fully characterized as autoimmune diseases like systemic lupus, rheumatoid arthritis or scleroderma, but that are induced by chronic stimulation of the immune system by substances which may react as adjuvants. This chronic stimulation leads to the emergence of these new signs and symptoms, which include fatigue, arthritis, myalgia, and neurological manifestations.
As Dr. Gorski points out, “any symptoms of fatigue, joint aches, muscle aches, or headaches might be ASIA!”
In a review of ASIA, Ameratunga et al. pointed out that “the definition of ASIA is imprecise and includes all patients with an autoimmune disorder as well as potentially the entire population.”
If it’s so broad it can apply to anyone, describing it as a unique syndrome is incorrect. It’s also problematic to try to associate it with anything. What do you measure? What do you study? How do you rule out other potential causes of something so broad and undefined?
The Evidence doesn’t support ASIA
As pointed out by Hawke et al. in a post titled “Tackling Antivaxers in the Literature” (on file with author), by 2017 95 articles were published about ASIA, but only 27 of them were primary research papers – that is, had new data – and of those, at least seven were mice studies. Extrapolating to humans from studies in mice is tricky. And for ASIA, especially, there is no well-defined animal model. The majority of the rest were small case studies – some, of a single case (see, for example, here or here.) T here are no large-scale epidemiological studies among them, and the range of exposures they address is large – including silicone from breast implants and a range of vaccines.
In other words, there is very little data supporting the syndrome, and the little available data tries to cover a lot of ground. Reviews called this out:
“At present, there is no evidence to suggest that ASIA syndrome is a viable explanation for unusual autoimmune diseases.”
And: “Current data do not support the causation of ASIA by vaccine adjuvants containing aluminum, which should be of reassurance to patients undergoing routine immunizations as well as to those undergoing allergen-specific IT.”
Not only does the data not support the existence of ASIA, but in some cases data clearly disproves it. HPV vaccines were a target of at least some of Shoenfeld’s ASIA claims (e.g. here and here, and where Shoenfeld served as paid expert witness in cases in the United States (here and here) and in Israel.
In other words, in the case of HPV vaccines Shoenfeld’s ASIA claims pit small (and problematic) mice studies and single-patient or case studies against data on millions of vaccine recipients. It’s no competition: Shoenfeld’s claims about autoimmunity from HPV vaccines have been thoroughly and categorically disproven. The point of this criticism is that the debunking of ASIA has not stopped him from repeating these claims.
A recent article is a good example of repeating claims of HPV vaccines and autoimmune diseases, in spite of the data: in an article from October 2019, Shoenfeld suggested a theoretical mechanism of how, they think, HPV vaccines could cause autoimmune diseases. But as mentioned, there is a large literature that shows that HPV vaccines do not cause autoimmune diseases, and those studies are never cited. In other words, the Shoenfeld paper is proposing a (highly problematic) model for how something that data shows is not happening could happen. And it never tells readers that.
For new adjuvants, too, a large review found no safety concerns, here, too, countering the claims in the ASIA literature.
Aside from the lack of data supporting ASIA, and the abundant data countering it in other areas, the ASIA literature suffers from other problems. First, there is an apparent lack of independent replication for ASIA: much of the literature seems directly tied to Shoenfeld. As summarized by Hawkes et al. in a presentation poster (on file with author):
“Of those 95 [publications], 32 (34%) have had Shoenfeld as a co-author, 59 (62%) in journals of which Shoenfeld is either the Editor in Chief or on the editorial board, and 56 (59%) were papers with authors who had co- authors published papers with Shoenfeld within the previous three years with an additional 5 (5%) papers published by member of the CMSRI Scientific Advisory Board (see Funding section). In fact there are only 14 (15%) papers on ASIA which do not fit into any of the groupings above linked to Shoenfeld.”
Further, several of the papers suffer serious problems. In some cases, the papers have what is either gross errors or intentional misrepresentations. For example, in a paper on MMR Shoenfeld and co-authors, trying to tie MMR to ASIA, wrongly claimed that the MMR vaccine contained “immune adjuvants” – which the MMR vaccine does not. This is a serious error on a very basic fact: an immunologist should know that MMR is a live virus vaccine, and that live virus vaccines do not contain adjuvants. Whether the problem was lack of basic knowledge or dishonesty, it is a serious flaw.
In another paper, Dr. Vince Ilannelli points to misuse of an article:
“Shoenfeld’s article on “Autoimmune/Inflammatory Syndrome Induced by Adjuvants and Thyroid Autoimmunity,” actually cites [claiming it shows an increase in autoimmune diseases – DR] a study which concluded that “There was no evidence of an increased risk of AD in women aged 9 to 25 years after AS04-HPV-16/18 vaccination.””
Two articles by Shoenfeld’s group were retracted for their problems. One article was retracted from the journal Vaccine, following criticism from commenters. Among other things the commenters pointed out that the numbers of mice experimented on were not correctly stated and that the age of the mice experimented on may have been misrepresented. The article was republished – with very few corrections – in the journal Immunological Research. Dr. Shoenfeld is one of the editors of the journal, and Hawkes et al. point out that the journal Immunological Research published 17 out of the 95 ASIA articles they found.
A second article was also retracted from the journal Rheumatology.
Another problem with these articles is that Shoenfeld not infrequently testifies in vaccine cases involving autoimmune diseases. Testifying in cases claiming vaccines cause autoimmunity does not disqualify a scientist from writing about vaccines and autoimmunity – in fact, writing might make a scientist a natural candidate for testifying – but it does create a potential for conflicts of interests, and requires the scientist to be as transparent as possible regarding such potential conflicts. Shoenfeld, to his credit, usually mentions that he has served as expert witness in vaccine court in articles about vaccines, and in two articles I have seen mentioned he was a witness in the case examined in the article. But in at least one article Shoenfeld omitted the fact that he was, in fact, serving as expert witness in two of the cases mentioned in the article and he later submitted the article as evidence in that case. After being called out on that, Shoenfeld attributed this omission to an unintentional error – but the statement in the original article was not, to my knowledge, ever fixed (it was still up this week), and readers would still be unaware. It is very possible that the omission was, indeed, an unintentional error, but if so, it is a large one – and not correcting it is concerning. It is also an error that, if repeated in other VICP cases, would be hard to catch, since Vaccine Court briefs are generally not published, many cases end in settlement, and even when there is a decision the facts may not be stated clearly enough to show the link.
At the least, it is fair to say that Shoenfeld’s publication practices raise questions.
In conclusion, Shoenfeld has promoted poorly-founded claims attributing risks to vaccines in a problematic way, potentially scaring people from vaccinating their children with no good basis, and helping the anti-vaccine movement.
It goes further, though.
Shoenfeld’s Anti-Vaccine Involvement:
Shoenfeld’s Hebrew Wikipedia entry states that:
“[Shoenfeld’s] articles about the risks of aluminum-containing vaccines were used by organizations that deny the need for vaccines and are fighting to stop them. Shoenfeld, in contrast, is not actively engaged against vaccines, but increases attention to side-effects and potential complications of some of them.”
That statement may have been well-founded when it was written – I cannot tell – but it is no longer correct. As the summary above shows, his ASIA claims go against the evidence. Repeatedly attributing to vaccines risks that the evidence does not support is the hallmark of the anti-vaccine activist. It is incorrect, today, to describe Dr. Shoenfeld as anything but an anti-vaccine activist, and his latest act – using his position as editor-in-chief to publish a glowing review of an anti-vaccine pamphlet – just reinforces that.
Moreover, Shoenfeld has repeatedly aligned himself with those “actively engaged against vaccines.”
Shoenfeld has, as set out by Dr. David Gorski, participated in multiple conferences that can be fairly described as anti-vaccine. The 2018 symposium – the fifth – was opened by anti-vaccine activist Claire Dwoskin. Ms. Dwoskin has, for years, been stridently anti-vaccine and contributed large sums of money to anti-vaccine causes.
Shoenfeld appeared on the anti-vaccine show “Highwire with Del Bigtree,” where he was interviewed by Del Bigtree himself, who is CEO of the anti-vaccine activist group “Informed Consent Action Network.”
Shoenfeld was a scientific advisory board member of the anti-vaccine Children Medical Safety Research Institute (CMSRI) founded by Ms. Dwoskin, until its recent demise. CMSRI appears to have stopped being active following the divorce of the Dwoskins, since Ms. Dwoskin founded it and it lost funding – but the site is still up, and at the least, Shoenfeld was part of it until it lost funding.
He is, in fact, still featured on their site in their “Vaccine Safety” Frequently Asked Questions:
“In an article published in the Pharmacological Review entitled “Predicting post-vaccination autoimmunity: Who might be at risk?” Dr. Yehuda Shoenfeld, editor of “Vaccines and Autoimmunity,” identified four groups of individuals who might be susceptible to developing vaccine-induced autoimmune/inflammatory syndrome induced by adjuvants (ASIA).”
For years, Prof. Yehuda Shoenfeld has collaborated with, promoted, and supported anti-vaccine groups and individuals. He has dedicated the past years of his career to support unfounded, counter-evidence claims about vaccines, claims that attribute to vaccines risks the data does not show they have. Some of his publication practices raise serious questions, both regarding his commitment to the scientific method, and regarding his ethics.
Shoenfeld is fairly and accurately described as anti-vaccine. He is not, at present, suited to teaching students on issues related to vaccines, or to holding positions of power in relation to scientific issues. Calling on him to resign from his position in Harefua is a good first step, but does not go far enough. I hope Israeli medical associations work to prevent him from causing further harm, and to contain the harm he has already caused. And I certainly agree with the anonymous Israeli immunologist and the science bloggers who called out and challenged his appointment to the Israeli Academy of Sciences and the Humanities.