As hard as it might be to believe, almost as long as there have been vaccinations, there has been an antivaccine movement, and as long as there has been an antivaccine movement, there have been parents who refuse to vaccinate. Indeed, in the 1800s, there were even groups with names like the Anti-Vaccination Society of America and the National Anti-Vaccination League. These days, antivaccine groups tend to hide their true nature with names like the National Vaccine Information Center and Generation Rescue, but the opposition to vaccinations is the same, just with different evils attributed to vaccines.
In a past that encompasses the childhood of my parents, polio was paralyzing and killing children in large numbers in yearly epidemics, the fear of which led to the closure of public pools every summer. In such an environment, the new polio vaccine introduced by Jonas Salk in the mid-1950s wasn't a hard sell. In fact, satisfying the initial demand for it was the problem, not parents refusing to vaccinate their children. Since then, more and more vaccines have been developed to protect more and more children from more and more diseases, to the point where the incidences of most vaccine-preventable diseases is so low that, unlike 60 years ago, most parents today have never seen a case or even known other parents whose child suffered from a case. Even as recently as the 1980s, Haemophilus influenza type B was a dreaded disease that could cause meningitis, pneumonia, sepsis, and death. Since the introduction of the the Hib vaccine a mere quarter century ago, Hib has been virtually eliminated. Most pediatricians in residency now have never seen a case.
As much of a cliché as it is to say so, unfortunately vaccination has been a victim of its own success, at least in developed countries. Parents no longer fear the diseases childhood vaccines protect against, which makes it easy for antivaccine activists to provide what I like to call "misinformed consent," by spreading misinformation that vastly exaggerates the risk of vaccines compared to the benefit of vaccinating. Parents who believe the misinformation conclude, based on a warped view of the risk-benefit ratio of vaccines, that not vaccinating is safer. Add to the mix fear mongering against the MMR based on Andrew Wakefield and his dubious 1998 case series that popularized the then-recent idea that vaccines cause autism, and it's no wonder that parents decide that not vaccinating is safer than vaccinating. If you believe the misinformation, it's not an entirely unreasonable conclusion. Then add to that the easy availability of "personal belief exemptions" to school vaccine mandates in many states, which include anything from religious exemptions to parents just signing a form that says they are "personally opposed" to vaccination, and it isn't a huge surprise that vaccine uptake has fallen in some areas to the point where outbreaks can occur. It was happening in California and my own state of Michigan.
The question then becomes: What to do about it? This question always brings up hard questions about how far the state should go to encourage vaccination, how many parents are vaccine-averse or even outright antivaccine, and the reasons why parents are vaccine-averse or antivaccine. Last week, Medscape published its Vaccine Acceptance Report for 2016, which looks at some of these issues.
Vaccine acceptance: The lay of the land
Early in the story, Medscape notes correctly:
The personal and public health impact of vaccine hesitancy, if it culminates in refusal, is substantial. Parents offer many justifications for declining vaccines for their children, and traditionally have not been easily persuaded by statistics about a vaccine's safety and efficacy, or horror stories about children who developed a vaccine-preventable disease. The burden on clinical practice in terms of time alone is significant, and providers must also grapple with such questions as how to provide quality pediatric care to unvaccinated children, how to protect other patients in the practice, and how to protect their own liability for any poor outcomes resulting from continuing to provide care to unvaccinated children.
The reasons behind vaccine hesitancy or refusal range from religious objections to personal beliefs, safety concerns, a preference for "natural" immunity, and a lack of accurate information about vaccines from a trusted source.
In response to this problem, Medscape administered a survey to health care professionals. 1,551 physicians, nurse practitioners, and physician's assistants in pediatrics, family medicine, and public health who worked in a practice setting where vaccines were administered to patients younger than 18 years were surveyed. Wherever possible, Medscape compared its results to a similar survey it conducted in 2015 in order to identify trends in vaccine hesitancy, refusal, or acceptance. Of course, one problem with this survey is that it's just of health care professionals; in essence, it only tells one aspect of the story and relates the impressions that health care providers on the front line have regarding vaccine refusal. That means that the reasons for vaccine refusal that are related are only what parents tell health care practitioners, which might or might not be the real reasons behind vaccine hesitancy or refusal.
One piece of good news is that the clinicians surveyed don't perceive an increase in vaccine refusal and hesitancy. Between 44-46% of clinicians perceive more acceptance of children's vaccines in general, children's measles vaccines, and the recommended vaccine schedule, while 42%-47% perceived no change in these same metrics. Only 9-14% perceived that these metrics have gotten worse since last year. This is encouraging, but it is only a perception. Whether it is an accurate reflection of what is going on is impossible to say. Similarly, whether the respondents are correct in their perceptions as to why vaccine hesitancy has decreased is impossible to say, but majorities respondents perceived that there has been more concern about infectious disease and more fear of children contracting vaccine-preventable diseases. Minorities were concerned that their children were denied admission to school, day care, or camp because they weren't fully vaccinated.
Some of the comments by respondents to this question on the survey included attributing the perceived increasing acceptance of vaccines to:
- Changing attitudes in the lay press—less glorifying and more scrutiny of vaccine refusers/press finally coming down negatively on vaccine refusers.
- State laws removing philosophical exemptions for vaccines.
- Taking more time to address all of the parents' concerns about vaccines.
- A new policy to dismiss vaccine refusers from practice
I've discussed the first one before from time to time, as I, too, have perceived a change in the attitude of the lay press over the last five years or so. Back in the day, when I first started blogging and paying attention to the antivaccine movement, a staple of my blogging was the examination of news reports by clueless journalists who treated vaccine stories and the idea that vaccines cause autism like any other issue, in which there had to be (at least) two sides. So for every quote by a vaccine advocate or pro-science advocate like Paul Offit, there would almost always be a countering quote by someone on the "other" side like Jenny McCarthy, Barbara Loe Fisher, or even Andrew Wakefield. Indeed, from time to time there were even very flattering profiles of Andrew Wakefield in press. Unfortunately, back then, the material for this sort of post far exceeded even my ability to cover all the articles I came across every week showing false balance. It was false balance, too, because the two viewpoints are not even close when it comes to scientific evidence for them. Billions of doses of vaccines have been administered with very few serious adverse events, while a veritable mountain of scientific studies attest to the safety and efficacy of vaccines. On the antivaccine side, there are anecdotes, confusing correlation with causation, and crappy studies and case series by the likes of Andrew Wakefield, Mark and David Geier, Brian Hooker, Christopher Shaw, Stephanie Seneff, and other antivaccine physicians, scientists, and scientist wannabes.
Then, beginning around five or six years ago, I started to notice a change. Fewer and fewer articles in the mainstream press exhibited what I considered to be false balance. I can't quantify it, and maybe I'm suffering from confirmation bias, but it seems unmistakable to me. I also noticed a new shorthand for dismissing antivaccine views: Mentioning Andrew Wakefield, how he lost his UK medical license, and his fraudulent 1998 Lancet case series. Yes, it seems to me that the discrediting of Andrew Wakefield by the UK General Medical Council and by The Lancet's retraction of his 1998 case series did far more to reverse the sad state of affairs in health reporting about vaccines than all the studies finding no link between vaccines and autism. I wish that it weren't so, because I like to believe that people can be persuaded by scientific evidence, but we know that that's not the primary way minds are changed. Anecdotes, stories, and statements from trusted people are far more effective, which is why I've resigned myself to this development and even sometimes use Andrew Wakefield as shorthand for discredited antivaccine beliefs myself. I would prefer not to, but at least this shorthand, besides being effective, has the added bonus of being true.
In fact, the idea that disconfirming data can even backfire and harden positions has a name, disconfirmation bias, in which we humans tend to expend disproportionate energy trying to refute views and arguments with which we strongly disagree. There's a related phenomenon known as the backfire effect, in which challenging a person's deepest convictions with disconfirming evidence results not in the changing of that person's mind but the strengthening of those beliefs. The process through which people manifest the backfire effect is sometimes called motivated reasoning, in which we are very good at finding facts and evidence that support our preexisting point of view. The more educated a person is, the better he is at motivated reasoning, which is why the most vocal antivaccine activists are so frequently highly educated and affluent.
Of course, we're talking here about deeply held beliefs. This would describe what I like to call diehard antivaccinationists and the leaders of the antivaccine movement. They are notoriously difficult to persuade, and it's rare that any of them flips to accepting the safety and efficacy of vaccines. Most parents who express concerns about vaccines are much less certain. Antivaccine beliefs are not deeply held; so the potential to reach them with evidence is there. More importantly, from my perspective, it is critical to keep the antivaccine misinformation spewed by the diehards (who can't be persuaded) from influencing those susceptible to their message.
But what about vaccine refusers?
Vaccine refusal: The lay of the land
Medscape asked respondents who perceive that vaccine refusal is increasingly a problem what reasons they've heard from families. Here are the reasons, ranked from most common to least:
- Fear of connection to autism spectrum disorder
- Concerns about added ingredients in vaccines
- Worry child will suffer other complications from vaccine
- Worries about "overwhelming" infant's immune system
- Distrust of pharmaceutical industry
- Believe child will get illness from vaccine
- Pain/stress of multiple injections for child
- Believe naturally acquired immunity is preferable
- Religious or political belief
- Doubt about vaccine efficacy
- Cost/lack of insurance coverage for vaccines
Note that the last concern was noted by only 8% of respondents.
Respondents also mentioned these reasons:
- Vaccines are not safe
- Worries about future repercussions of vaccines
- Diseases to be prevented are not that bad (or, as I like to call it, the Brady Bunch fallacy)
- Too many antigens given at once
- Fear that vaccines are a government plot
You'll also note that every single one of the concerns that can be addressed with evidence has been discussed on this blog at one time or another. The evidence is clear: Vaccines do not contribute to autism. The concern about vaccine ingredients is one that I've dubbed the "toxins gambit" because, although there are chemicals such as formaldehyde in vaccines, they are present in such trace quantities as to be safe. Indeed, the amount of formaldehyde in infant vaccines is much smaller than the amount of formaldehyde circulating in the infant's bloodstream from normal metabolic processes that generate it. "Natural immunity" might be more long lasting for some vaccine-preventable diseases, but the huge downside to natural immunity is that the child has to suffer the disease, with all its attendant suffering, morbidity, and even potential risk of death to achieve it. Worse, in the case of measles, "natural immunity" involves a suppression of the immune system that leaves children more susceptible to other diseases and results in increased mortality in children who have had the measles, an effect lasting up to three years post-infection. In other words, in the case of measles, at least, the benefits of the vaccine go beyond measles.
One issue that we who advocate vaccines probably don't pay enough attention to is parental concern over the pain and stress of multiple vaccinations. That concern could be fairly easily overcome when it's just one shot at a visit, but when a child gets two, three, or even more shots in a single visit, it can trigger a very deep protective instinct in parents that can cause a great deal of distress and lead them to start to wonder if all these shots are really necessary. Alice Dreger, who is pro-vaccine (although she has an unfortunate and irritating penchant for portraying vaccine advocates as frenzied self-righteous zealots), was honest enough to talk about her experience with this instinct in herself:
My maternal instinct was riled with every new round of shots and cries and tears: I remembered one particular visit to our paediatrician when my gut instinct had a sharp argument with my brain. I can't even remember what the vaccine was; I just remember that Gut was yelling, "Enough already! Stand between our baby and that needle!" Trying to stay calm, Brain answered: "Vaccines are safe, and necessary not just for our baby's health but for the health of those around him, especially children more vulnerable than him . . ."
Vaccines aren't the only medical procedure performed on children that provokes this primal instinct, but it is by far the most common. Mild reactions after vaccinations, such as fever, are not uncommon, as well. Such reactions, when they happen, only serve to fire up parental instincts even more next time. How physicians, nurses, and medical assistants deal with this natural anxiety in a parent who might be predisposed to become vaccine-averse or even vaccine refusers can make the difference.
It's not all vaccines: HPV and flu vaccine resistance
Just as there are gradations of antivaccine views, from those who fervently believe that vaccines are ineffective and dangerous to those who have been influenced by antivaccine propaganda and fear that vaccines could harm their child, not all vaccines produce the same level of resistance. For instance, Medscape found that the vaccines most likely to be refused are the human papilloma virus (HPV) vaccine (Gardasil or Cervarix), the flu vaccine, and the MMR, while the least likely to be refused is the Haemophilus influenza type b (Hib) vaccine. It's not surprising that the Hib vaccine is an easier sell, given how deadly the disease was up until the early 1990s, which is when the vaccine basically eliminated the disease except for a handful of cases every year. It's also not surprising that resistance to the MMR vaccine remains high, given that even 18 years later Andrew Wakefield's fraudulent study still reverberates, nor is it particularly surprising that flu vaccine resistance would be high given that people still have the mistaken impression that the flu is not a serious disease coupled with the variable and less than optimal efficacy of the flu vaccine.
I'm, however, somewhat surprised that the hepatitis B vaccine didn't rank higher on this list, given the widespread perception of hepatitis B as a sexually transmitted disease and the frequent attacks of the birth dose of this vaccine by antivaccine zealots, but I'm not at all surprised that resistance to Gardasil is the highest because the HPV strains that cause cervical cancer are sexually transmitted. Not surprisingly, the reasons parents give are, in order of frequency from most frequent to least frequent:
- Parents did not perceive their child to be at risk for acquiring a sexually transmitted infection
- Parents have concerns about the potential side effects of the HPV infection
- Parents voice concerns that the vaccine promotes sexual activity
- Parents believe that not vaccinating their children doesn't harm anyone else.
- I'm unconvinced that the benefits outweigh the risks, so don't promote as strongly as other vaccines
Fortunately, that last reason was only 7% of respondents, but that's still rather high. It's also very critical, as what this study probably didn't pick up is this factor discussed by Medscape:
Other research supports the finding that provider ambivalence plays a role in HPV vaccine acceptance. Although most providers reported in a recent study that they usually discuss the HPV vaccine at the 11- or 12-year visit, only about 60% of pediatricians and family practice physicians strongly recommend the vaccine to parents. Without a strong recommendation from clinicians, it is unlikely that parents will be able to overcome other reservations about the vaccine, such as the fear that it will encourage sexual activity, concerns about safety, or relative unconcern about HPV disease.
In other words, if clinicians don't, through action and word, let parents know that they consider the HPV vaccine to be very important, then why on earth would parents think it important enough to overcome their other concerns? These results also make it hard not to note that many US families are living in a fantasy world if they believe their teens are not at risk for acquiring a sexually transmitted disease, and it's a myth that the HPV vaccine promotes promiscuity. Yet these mistaken impressions leave HPV vaccine uptake far below what it should be.
Strategies to counter vaccine hesitancy
Medscape also asked the clinicians it surveyed what strategies they found most effective at encouraging vaccination in families who hesitate or refuse vaccines. They found these strategies mentioned, in decreasing order of frequency:
- Providing evidence-based responses to concerns
- Telling parents you would/do vaccinate your children on the recommended schedule
- Providing info on potential morbidity/mortality of vaccine-preventable diseases
- Offering an alternative schedule
- Refusing to accept patients who won't adhere to the recommended schedule
I note that, even though it's the number one answer, "providing evidence-based responses to concerns" was only mentioned by 63%. Parents who are persuaded by evidence are almost certainly the ones least resistant to vaccines, given the backfire phenomenon. It's not part of their world view or a deeply held belief. Notice, however, number two: Telling parents you would vaccinate. This is similar to a question I not infrequently am asked by patients with breast cancer: If I were your mother/wife/sister, what operation would you recommend? Again, the human connection and personal anecdotes are often more powerful than data.
As Medscape puts it:
Rather than a lack of information about vaccines, there is information overload from countless disparate sources.[14] Providing accurate information about vaccines to correct misinformation and misunderstandings is one of the most common strategies used by clinicians to increase parents' confidence in vaccines. However, more than a few respondents were cynical about such strategies as sharing the science or telling "horror stories," which, as one respondent said, "work rarely. Most antivaxxers are not influenced in any way."
Again, just providing accurate information can be effective, but it is not enough, and it almost certainly won't work with antivaccine parents, as opposed to just vaccine-hesitant parents. Other examples cited by Medscape are in line with this:
- Telling stories from early in my career when many current vaccines were not available and I watched children die from vaccine-preventable diseases
- Reminding parents that providers, too, want what is best for their children
- Explaining that healthy children must be vaccinated to protect more vulnerable children (kids with cancer, autoimmune diseases, transplant recipients, newborns) who can't be vaccinated
Other suggestions included:
- Increase transparency about vaccines, better risk-benefit data, better tracking of adverse events
- Public service announcements with personal stories from families whose children's lives have been affected by vaccine-preventable diseases
- More flexibility in alternative vaccine schedules
- Eliminate the vaccine court and restore the right of patients to sue vaccine manufacturers
- More patience from providers. Parents may be frightened and need a little space and understanding. Most will come around.
The last one is probably the most useful and likely to be effective, while health authorities already do public service announcements with personal stories of children harmed by vaccine-preventable diseases. The rest of these ideas range from being truly bad (eliminate the vaccine court) to being based on a misconception (increase transparency; vaccine safety data are already pretty darned transparent), to being medically a bad idea (more flexibility in alternative schedules).
Remember, it's not just about vaccines
Overall, the 2016 Medscape survey probably does a decent job of capturing healthcare providers' attitudes and perceptions regarding vaccine hesitancy. It doesn't, however, look at the views of actual parents, and in my experience many providers are blissfully unaware of one thing: Whenever a parent refuses vaccines for her child, it's almost always about more than just vaccines. I like to cite as an example a post from an antivaccine blog entitled "Why don't you vaccinate?", in which a father named Matt tries to answer that very question. The various reasons he gives are, of course, easily refutable and in fact I refuted them when that article was first published, but it's worth looking at them anyway:
- It's MY choice.
- Many vaccines are designed using aborted fetal tissue as a growth medium.
- Many vaccines contain foreign animal DNA.
- The ingredients in vaccines scare the crap out of me.
- Herd immunity does not exist.
- We've traded disease epidemics and natural immunity for neurological and auto-immune epidemics and artificial, temporary immunity.
- I don't believe that vaccines eliminated diseases.
- The vaccines aren't as effective as you're led to believe.
- Financial incentives and conflicts of interest turn me off.
- Vaccine manufacturers are immune from any and all liability.
While it's easy to laugh at the utter ridiculousness and cluelessness of some of Matt's reasons, such as the claim that herd immunity doesn't exist (it most certainly does), vaccines cause neurologic and autoimmune diseases (they do not), and how Matt "doesn't believe" that vaccines eliminated any diseases (seriously, who cares what Matt "believes" about science, and I have two words for him: smallpox and, hopefully soon, polio), did you notice something about the reasons? Several of them have nothing to do with whether or not vaccines are safe and effective. For instance, the concern about whether vaccines are made in "aborted fetal tissue" is obviously incorrect, although 50 year old cell lines derived from aborted fetuses are used in the manufacture of some vaccines, which is a very different thing. However, concern about the source of cells used to make vaccines is not about whether these vaccines work or not; it's about moral values, a world view, and deeply held beliefs, about whether vaccines will somehow sap and impurify our precious bodily DNA. The same is true about financial incentives and the belief that vaccine manufacturers are immune from all liability (they aren't, of course). As exaggerated as these reasons are, they speak to a certain world view of which antivaccine beliefs are but a part. It’s also how “they” view “us” (i.e., scientists, physicians, and vaccine advocates), as I have discussed several times.
Perhaps most important is what Matt lists at #1: It's MY choice. Notice , in his original post, Matt starts with #10 and works his way to #1 in a countdown; so #1 is listed last. The buildup only emphasizes the importance of this reason, like a top 40 countdown does for the number one hit. Matt sees the requirement that he vaccinate his children if he wishes them to go to public school as an unacceptable affront to his own ability to choose. This is not surprising, given that Matt describes himself as a "a conservative millennial," which means that politically he is opposed to anything he views as overweening governmental power; e.g., school vaccine mandates. It's also a common reason among antivaccine activists and part of the reason that the appeal of the "health freedom" movement (which I like to characterize as the freedom of quacks to ply their quackery but its members see as the freedom to choose their own health care) is so potent. As you can see from his post, he's also not bad at motivated reasoning, able to marshal information supporting his point of view while dismissing the much more powerful evidence refuting it.
When trying to persuade parents who are merely vaccine-averse but for whom vaccine hesitancy or refusal is not part of an overall world view that is inherent in their core beliefs, traditional methods of persuasion using evidence, trust between physician and patients' parents, and anecdotes have a chance of working. When it comes to someone like Matt—or any of the bloggers at, for example Age of Autism or The Thinking Moms' Revolution—such methods will almost certainly fail or even backfire. They remain the last, most difficult challenges. I fear that the Medscape survey, while providing me hope that the prevalence of vaccine refusal is probably decreasing (or at least probably not increasing), it doesn't give me much confidence that most primary care physicians understand where antivaccine views come from.
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"3.Many vaccines contain foreign animal DNA."
And so does my steak.
"I have two words for him: smallpox and, hopefully soon, polio"
Don't forget Rinderpest! Less famous than smallpox was or polio hopefully will be, but it was a magnificent success regardless.
I'm always amazed at how people who should know better -- and claim to know better -- don't act like they know better. They don't even act like they know better when life and health are at stake. It's as if the brain has decided to do its own thing even when the stakes are high... Almost like a reflex and less like a reasoned (or reasonable) response.
That's what I get from most antivaxxers I interact with, just a knee-jerk reaction and little substance.
Ren@3: "That’s what I get from most antivaxxers I interact with, just a knee-jerk reaction and little substance."
As I've observed before, the True Woo is a paranoid narcissist, ignorant and impotent, raging against a world she does not understand and cannot control. Her ego, her social status, her entire identity and purpose in life; everything that she is hangs upon her unfaltering maintenance, propagation, and defense of those beliefs, for without them she has nothing; she is no-one.
By questioning or criticizing her beliefs in any way, you are personally perpetrating a direct and potentially deadly attack upon the person herself, and there is little most people will not do to protect themselves when their very lives are threatened—up to and including throwing others under the bus with zero consideration or remorse. Anyone can rationalize just about any belief or behavior when the rewards for doing so are sufficiently great, and/or the penalties unbearably awful should they not. It just comes a lot more easily to those who've never learned to count past One.
More patience from providers. Parents may be frightened and need a little space and understanding. Most will come around.
I must disagree with this part of the Medscape report, based on my own clinical experiences over the last 13 years and also this recent research finding showing that 72% of parents of newborns had already decided on whether/how they were going to vaccinate before their first doctor visit. ( https://aap.confex.com/aap/2015/webprogram/Paper32305.html )
It would have been more informative for Medscape to survey the practices that have expelled vaccine-refusing parents as to what finally drove them to do that. You know my reasons, and I suspect it is similar to other practices (ie. risk to newborns and immune susceptible patients, tired of battling the words of quack doctors who, unlike Wakefield have not been disciplined in the US, and the realization that no amount of time is going to change these folks' minds once they buy into all the nonsense in the AV echo chambers online.)
This isn't the worst thing (please let me finish before heads explode) and can have a very positive effect on vaccine-hesitant parents. Back in my days on "Mommy Boards" I was able to get a lot of moms to start vaccinating their children by starting off slow e.g. "Hey why don't you start off with Pentacel and when you see everything is fine, do HepB the following month." This allowed them to do what they really wanted to do which was vaccinate but give them an out for their fear without validating it.
Parents who are vaccine hesitant (which are probably the vast majority) can be convinced with a bit more light-handed approach. They can easily be turned to a Bob Sears-type doctor (or even worse) if they are hammered over the head. That is not to say I don't understand and agree with some physicians who enact a blanket policy for a vaccination schedule who get inundated with anti-vaxx parents who are probably insufferable.
A number of years ago, I had a mother bring her son into my office to report a dog bite. The dog could not be found, so following standard procedures I was recommended the boy (8 or 9 years old) go through the rabies series. The boy was on a medical card, so there would have been no cost.
The mother refused even after having it explained that if the boy contracted rabies he would die. Her reason for refusing the vaccine for her boy: he is afraid of needles.
Luckily, he didn't contract rabies.
There is enough flexibility in the timeline to stagger the shots with certain combos and still maintain the schedule.
Maybe a good marker as to whether the primary care provider correctly applies Orac's as argument presented here would be to measure the community HPV vax compliance rate.
Something else not provided in the Medscape study is the idea of some sort of federal oversight and accountability in cases where states aren't willing or, it seems, able to enforce the evidence-basis on a practioner that willfully disregards it, and even capitalizes on it.
As a pediatric nurse I have struggled with families digging in against reason. Only this year with the rise of Trump I have learned to accept that for many people Feelings>Reason. Using reason with antivaxx parents only makes things worse, just as using reason with a Trump supporter is a waste of time.
I am at the point that I think schools need to exclude unvaccinated children, except those with a medical exemption. Religious or "philosophical" exemptions are too easily abused. If we cannot reason with such people then we have to go to ostracizing them from public benefits. You have the right to hurt yourself but not the rest of us.
There's quite a lot to digest on this topic. Not necessarily what the antivaxxer perceives or becomes misled about, but an argument more targeted toward what the professional primary care provider does, or may not be doing, and maybe a why on the provider.
You know, back in the 1800s, it made a bit more sense to be antivaccine, considering the state of medicine (and the level of medical ignorance among the general public). "You want to wound my child and infect him or her with disease so that they don't catch a worse version?"
Nowadays, of course, we have no such excuse.
I appreciated the story about the protective mom's inner dialogue, because I have the same reaction when my kids get shots. (Especially when they're young babies.) Everything in me is screaming "No! Stop hurting my babies!" My oldest daughter gets (mild) fevers after EVERY SINGLE SHOT, too. However, I dearly love the fact that my kids are unlikely to develop many serious infectious diseases, and that of course outweighs my gut distaste for the process.
@Heidi_storage: There's a great article on "Thinking Person's Guide to Autism" entitled My Baby Cried Louder than Science written by a pro-vax Mom who briefly panicked when her baby appeared to be having a vaccine reaction; I highly recommend it.
For the people that say measles is not a big deal:
Myanmar outbreak mystery solved: Measles behind deaths of 30 plus people in remote north
Generally speaking, it's hard to reason someone out of a position he didn't reason himself into. That's true of a lot of things in general, but it's especially true of hard-core anti-vaxers.
But there are many who can be reached: people who may have heard some of the anti-vax propaganda but are not committed to that position. These parents can be persuaded by pointing out that certain rumors they have heard are wrong, and explain why.
There is another category that deserves particular mention:
It's an indictment of our medical system that there are parents in this situation, but if the choice is between "baby gets her vaccines this month" and "baby eats this month", the latter is actually the rational position. If the baby doesn't eat, her vaccination status is not going to matter. This situation most commonly arises in states which have not opted into Medicaid expansion, and is caused by irrational people of a different kind, namely certain politicians. All that doctors can do in this scenario is write to their state legislators recommending that they remedy this situation.
I think it's necessary to distinguish CHIP and ACA here, but I'm not in a position to do it right at the moment.
@Eric Lund: even before ACA, I expect the Vaccine For Children cost took care of most vaccines cost. That wouldn't change the problem of costs for doctors visits though, I think - though I'm not sure even of that - I don't know if VFC has any provision for that.
Of course, cost of vaccines is not the only access problem, nor even doctors' visit. Time to go to the doctor is also an issue, and a parent might fall behind when the choice is get the child vaccinated or get fired.
Yes, doctor visit costs may be an issue:
http://www.cdc.gov/vaccines/programs/vfc/providers/questions/qa-parents…
"Q: The vaccines are free, but what if I can't pay for the doctor visit or the vaccine administration fee?
A: Although the VFC vaccines your child may receive are absolutely free of cost, the doctor still has the right to charge a fee for an office visit.
If your child is on Medicaid, that office visit is paid for by Medicaid.
If your child is not on Medicaid, you are responsible for making appropriate payment arrangements with your doctor in relation to office visit charges.
Doctors participating in the VFC Program also have the right to charge an administrative fee for giving your child a shot. However, they are required by law to administer the vaccine even if a child cannot afford to pay the administrative fee. This means that the administrative fee, unlike the office visit fee, must be eliminated if you are unable to pay."
Why is Ilena Rosenthal shown snipping the syringes? I don't recall her beating the drum against vaccines.
Orac :
" It seems unmistakable to me"
I would agree: coverage of the anti-vaxxers DID change dramatically post- striking off of Andy.
@Sarah A. Yes, excellent article. None of my kids are (to my knowledge) autistic, but I can completely sympathize with the author's reaction. It is so nice that her pediatrician was kind and understanding; I remember a very sweet pediatric nurse calming me down one Sunday morning when I was convinced I'd given my one-month-old pneumonia.
@ Science Mom #8: My head didn't explode. My experience (before I expelled vaccine refusers) was that the parents I let delay/stagger vaccines almost always never caught their kids up on vaccines. I know there's a reference out there that supports this, too, but I can't find it. And tying into what Dorit says about the doctor visits--I didn't derive extra revenue from extra visits by parents who were spacing out vaccines as they wouldn't pay a nurse or doctor visit fee for those visits. Plans pay a fixed fee for each vaccines (typically about 10% over my cost--whoopee, Walmart would go out of business on that margin and so would I if I didn't see children for things other than vaccines) and a shot admin fee which didn't cover the other costs associated with vaccines. So letting parents space out vaccines tied up my exam rooms (I only have a finite number of them) with shot visits that then also kept me from seeing same day sick visits unless I wanted to tag a couple of more hours onto my clinic day (and then I have to convince staff to hang around and pay overtime as well). Plus you don't want to bring your kid into a pediatric office any more than is needed (and spacing out vaccines brings a lot more unneeded visits). because, yes, your kid can get sick in my waiting room.
Brought up to Mr Woo how relieved I was to see a picture of our two-month-old granddaughter at her shot visit. I mentioned he had said her parents delayed vaccinating. He then went on about the "thirty vaccines" they give to babies the day they are born. I suggested they only give the Hep B... he then goes on about that...
My son is watching, and I am behind Mr Woo. I mouth "science" to my son as Mr Woo says anyone believing statistics is only using faith.
Mr Woo is completely irrational about most scientific facts - vaccines, anthropogenic global warming... He is a Trump supporter and definitely not able to be persuaded on anything. Strangely, he is college educated. However, he is retired and white, so he still fits the typical profile, except for having a BS in sociology.
@Eric Lund-The Vaccines for Children program provides vaccines at no cost to the patient. Most health departments participate in VFC and do not charge a doctor's visit fee. Sometimes an administration fee is requested, but no one is turned away due to inability to pay.
Narad@24: You know, selfish people.
Vaccination among healthcare workers in particular. I do not know vaccination rates among the nurses and what not, but I can think of two people off hand I work with in the cleaning department, who do not vaccinate. It is perplexing to me that they don't. Where I work has a program called the My Health Reward, it is an incentive program for employees to lead healthy life styles. If parameters are met (being current on vaccinations is one of them) then we get an extra $360 a year. If people opt not to vaccinate then they are supposed to wear a mask their entire shift. Unfortunately management is bad at enforcing this policy. The two I know who don't vaccinate, also don't wear the mask.
Sarah @26: A friend of mine who's a nurse posted some ridiculous thing on Facebook about how terrible flu shots are. Before I even had a chance to formulate a response her dad responded with a Snopes article refuting her article. Then my friend was "Oh, you're right!" and went off to get her flu shot (so she didn't have to wear a mask).
Some people do learn!
On the topic of Andrew Wakefield, the damning evidence that came out in his GMC fitness to practice earing that led tohim losing his licence and the full retraction of his paper have had a significant impact on the way the press has reported the anti-vaccine movement. It was one of those watershed moments when a lot of the press realised that the hero of the anti-vaccine movement was a fraud.
@ Narad #24: When you see a patient, you can often bill for a doctor or a nurse visit CPT code. However, for a shot-only visit, you cannot bill a doctor or nurse visit CPT code (if all you are seeing them for is vaccine(s), then you can only bill the CPT codes for (1) the vaccine(s) and (2) the administration of the vaccine. So if someone is coming to see me for one vaccine at a time, I billed for single shot/adminstration CPTs every visit, which brings in no more revenue then if the vaccines were given on schedule and not spaced out. Again, though, this spacing out of vaccines removes visit slots from my schedule that could be used for same-day sick patients--which are both critical for good patient care in pediatrics and also a source of revenue that made up for the abysmal payments I received for vaccines (and this is why pediatricians are the lowest paid of physicians--1/3 of my overhead was vaccines and the ROI financially was horrible). I've dropped insurance plans because they weren't even paying me cost on vaccines, which ought to be illegal.
#7 Rich Bly
The mother refused even after having it explained that if the boy contracted rabies he would die. Her reason for refusing the vaccine for her boy: he is afraid of needles.
Luckily, he didn’t contract rabies.
And it crosses my mind she may be lucky that he does not find out about this when he's 20.
But then I come from what used to proudly? call itself the rabies capital of the world and I am abslutely peranoid about rabies
@14 Eric Lund
There is another category that deserves particular mention:
Cost/lack of insurance coverage for vaccines
However that does not explain the low rates of vaccination take-up in other countries where they would be supplied routinely during a well-baby visit at no cost in countries with a more rational,(cough) medical care. Australia, Canada and the UK all seem to have this problem although I don't have figures on the relative rates.
I think while the Medscape study is interesting, I would not try to establish any kind of policy based on it (Sorry to the USians, I was thinking of provincial or federal health care policy) before doing a lot of in-depth interviewing & perhaps some focus groups with both non-vac and vac parents. The views of the care providers and receivers might be very different. Also I am I right that it is the mother who almost always takes the child to the doctor? If so Medscape has missed the other half of the family unit.
@Eric Lund-More about the false dichotomy between vaccine and eating-Most low income infants are eligible for both food stamps and WIC.
@Sarah-According to the CDC, the percentage of US nurses (RN) in all types of settings getting the flu vaccine was 90.5%. For non-clinical personnel it was 68.6%.
One of the ones who doesn't vaccinate seems to have mental health issues. She is very paranoid, loves conspiracy stuff, and one time came back to tell me about how her sister (who is a doctor in Mexico) told her that the priest who was poisoning her (this is part of her paranoia) must have been using this metal stuff, and that is why her chest pulls toward magnetic fields. I told her if she is having thoughts like this she needs to talk to a doctor at work, not her sister.
The whole WIC's-a-gonna make me vaccinate trip was a routine topic at MDC before I bailed quite a few years ago.
@Narad-That wasn't exactly what I meant, though that is a good point. I never worked for WIC, I worked on the immunization side of public health, until, like you, I "bailed" back in 2000. It's just a false dichotomy, though one that comes up often, to say that it's "vaccine or food".
My question was more whether you could charge cash on the barrelhead for the service.
Mark Thorsen @18, I think that's supposed to be Jenny McCarthy.
6. ...artificial, temporary immunity.
Yeah, there is indeed such a thing. The problem is, that isn't immunity from any vaccine, it's gamma globulin.
In a bit of genuine weirdness, Stagmom seems to be desirous of getting George Takei to come out against SB 277. I'm not really part of the Twattosphere, but I'm hoping against hope that some hilarity emerges.
Thanks a lot Narad; those comments are derpilicious.
I was wondering whether the "Joe" there is in fact Joe Harris/ccdaddy57, whose lips once fell off because of GMO corn triffids.
Hello all
I don't want to be a prophet of doom; but we need to plan for the worst, but hope for the best. If support against vaccination starts to rise in the general populous (from my understanding its isn't in general), we may likely be to be back to the "bad-old days" of preventable-disease outbreaks/pandemics. We need to plan for the sudden addition of very large numbers of patients (1000's) on a annual cyclic-basis (eg. like what I have read about Polio). It is unlikely to get to that, but we need to plan as though it is a certainty. We don't want to get caught unprepared.
Ooo Ooo, did you see this gem from that wordsmith Benedetta?
Oh and:
What a sad little echo chamber they live in.
To increase vaccine compliancy, the CDC needs to tell all the vaccine-damaged people that they are actually suffering from a virus. This will have the positive side-effect of creating the need for more vaccines($), and also further increasing compliancy out of fear.
We just need to name a mythological virus.
Tenfold Shrew @44: If you stepped on a rusty nail in a horse barn, would you get a tetanus shot?
@Justatech
If you got buttraped by Tommy Lee would you get an HPV shot?
Hmmm, do I smell some old sock puppets?
@Chris, #47, that isn't old sock puppet smell, that's just the smell of bullshit. ;)
I noted that she's recently stated that she's only 60 years old, which I found surprising given some of her other comments. I'm not going to bother collating them, but I got the impression from one recently that her husband was (or would have been) a centenarian and her father is Methuselah.
In any event, Flying Monkey Squadron Leader Maurine Meleck has relocated from South Carolina to Florida. I think that this entry is probably AoA's winner for today:
@ Narad, Good grief as if they couldn't become more unhinged and out of touch with the world.
I can only assume that this was an attempt at humor; Meleck was a rather prolific "contributor" to the Augusta Chronicle. But man, oh, man.
I think the odds of that happening are between slim & none. I don't recall Uncle George opining on SB277 when it was in the legislative process, but I do know the Opposition was courting quite a few celebrities.
BTW, there's a hearing on one of the suits against SB277 on Aug 12. The purpose of the hearing is to decide if there will be a stay on implementation of the law. I believe a certain prominent vaccine-advocate law professor will be attending the hearing. I look forward to her report.
Monica @46: What a perfectly nasty thing to say. And totally pointless: The HPV series (which I had years ago) works before infection. Some vaccines, like the tetanus shot, also work to prevent illness if given right after infection.
From your statement I can conclude that you are 1) very nasty and 2) not very informed about how various vaccines work.
Yah, I know. I also tried to update the docket and found that my RECAP is apparently not working, and I'm out of free PACER buxx for the quarter. As a result, I'm having trouble sorting out document 39, Plantiffs' objections to the Rich and Schechter declarations.
@Science Mom-Regarding post #6 (I know, I'm a little slow on the uptake) My best response to parents wanting to "go slow" is to tell them their kid is unprotected longer if they do that. Particularly, they should be protected against pertussis and Hib. While I would never recommend that anyone skip any vaccine, those are the two I'd prioritize if a parent insisted on a spread out schedule.
Wzrd1: "that isn’t old sock puppet smell, that’s just the smell of bullshit."
Well, a few minutes after I posted that I learned one was banned by Orac for being a sock puppet. The silly thing then stalked me a JustTheVax. Even while traveling on our lovely interstate highway system* six hours per day this week I seem to annoy the trolls.
* which seem to be under renovation. Great swaths of I-90, I-80 and I-84 are being replaced... not repaired but scraped away and being completely freshly built, which includes many bridges!
Hello to the US,
I'm every now and then right in the middle of a discussion with Anti-Vaxxers.
One Argument, I'm stumbling over and over again, every time I am quoting your blog to debunk a "study" or a belief, somebody is telling me that you are "big in circumcision" and hence "not scientifically trustworthy".
Search function in your blog didn't come up with "big in circ" - I could establish that you are rather indifferent about this seeing that you are an oncologist and it is highly likely that you have no "touching areas" here.
But I would like to hear from you firsthand if this is true? I would hate to jump to conclusions without evidence.
(my submitted email-adress is real and not made up, just in case).
@Tenfold Shrew
If you need to lie to make a point, the point is not worth making. It would be far more effective, although no doubt more difficult, to educate people to understand science.
Oh, dear, someone seems to have a really serious case of asshurt: Fendelsworth is now impersonating me on AoA. This almost makes having to survive the weather in a tattered slip all worthwhile.
@ Narad, wow that is really pathetic. Did you see this partial response to him? It's a keeper.
What a freaky little hive they have there.
The parenthesized exclamation point in the salutation is the best part.
Is it possible to hide oral vaccines in food? Like MMR popsicles and DTaP lollies?
We could put the swine flu vaccine in bacon.
If the vaccines could be administered orally, don't you think that that would already be done?
Or do you think that doctors greatest joy in life is sticking an inch of steel into children, when alternative and equally effective methods are available?
Oh, the last time I had bacon, (yesterday morning, to be precise), it has to be cooked. Even oral polio vaccine can't be cooked, as it's a live, attenuated vaccine. Cooking it would turn it into a dead, denatured nothing.
@Science Mom: I avoid AOA like I avoid fleas (and the plague). But they seriously went there? Measles vaccine in 1918? I guess history is something else they fail at - reading dates, I mean.
Well, really, name one conspiracy theory that doesn't, in the end, require a time machine to accomplish the "conspiracy"?
So, reading comprehension and temporal comprehension, or at least, an understanding of how causality works in this universe.
@Wzrd1 If the vaccines could be administered orally, don’t you think that that would already be done?
This is the efficiency fallacy.
Did you know that GE created an alloy for lightbulb filaments specifically to reduce it's longevity? Certain filiments can last decades.
Sometimes an industry creates a niche market and actively prevents technological or scientific progress in that area.
"This is the efficiency fallacy."
Erm, no. When you hit six sigma certainty of ineffectiveness, that isn't an efficiency fallacy at all, it's called cooking causing protein denaturing and digestion of proteins, plus no reasonable method for the vaccine components to magically cross into the blood stream or interstitial and provoke an immune response.
Orally delivered vaccines wouldn't even provoke diarrhea. Or a fart, for that matter.
Worse, to further undermine your notion, vaccines wouldn't really need to be anywhere near as sterile, if used rapidly, as sterility isn't required for oral consumption.
Yeah, you'd be amazed how many fungi, bacteria, protozoan cysts and viruses you ingest in your food, just from the time it leaves the pan until it reaches your mouth, to be further inoculated with oral flora and fauna.
Plus what was on the food before cooking, but denatured into their components, with anything nearly surviving intact, digested into base pairs at most.
That would be monumentally self-defeating for pharmaceutical companies. Orally administered, efficacious vaccines would be a boon to the industry. Think about it, drink/eat your vaccine or get jabbed with it?
That we are seeing new delivery methods being tested - like vaccine "patches" speaks volumes to the industry drive to move away from needles and injections - if they prove to be as safe and have the same efficacy as current vaccines.
Alas, the influenza nasal spray vaccine method isn't recommended any longer, being largely ineffective. :/
Is that you Fendelsworth?
Irony meter says this is not meant to be taken as a serious proposal. Methinks it's either just inserting an available off-tangent joke for the sake of some humor alone, or a light-hearted dig at fear-of-needles for 'wussyness'.
@sadmar #72, damn! I was holding out for my cholesterol pill coming in bacon!
And insulin coming in a sugar cube.*
*Yeah, yeah, I know, it isn't simply consumed sugar that's the problem, it's either insulin resistance, insufficient insulin secretion or no insulin secretion.
Really, the same is true for that bacon, as not a lot of cholesterol is absorbed intact, the liver manufacturers it.
@Wzrd1 If the vaccines could be administered orally, don’t you think that that would already be done?
You may have other arguments why oral vaccines are not more universal, but above is what I call the efficiency fallacy.
Another example would be: If they could make make cars that get 100 miles per gallon, don't you think that would be done already!
These naive arguments miss the mark because some companies simply care more about the status quo than they care about efficiency.
The oral polio vaccine is, well, oral. And there are rabies vaccines for animals that are delivered by food as well. And maybe a plague vaccine for prairie dogs?
But yes, generally oral vaccines are hard.
So how is an attenuated live vaccine attenuated?
How do they reduce the virulence without totally destroying the virus?
Michelle @76: Which live attenuated vaccine?
In the very earliest days (the first rabies vaccine) the attenuation was done by passing the virus through rabbits (I believe).
Now I imagine it's done through molecular methods.
There are programs in the US and Canada to control rabies by distributing oral vaccines in baits.
https://www.aphis.usda.gov/aphis/ourfocus/wildlifedamage/programs/nrmp/…
Success so far has been mixed, but research continues.
Or more likely the most vile stench of socks.
The latest commercial rabies vaccine (for cats) is live, unadjuvanted, and canarypox-vectored. The human version is inactivated.
This, predictably, cluessly wanders back to Bruesewitz (boldface added):
"Comment k exempts from this strict-liability rule 'unavoidably unsafe products.' An unavoidably unsafe product is defined by a hodge-podge of criteria and a few examples, such as the Pasteur rabies vaccine and experimental pharmaceuticals."
Why doesn't inactivated vaccines work orally?
This stuff is interesting. Maybe I should buy a textbook.
Had anyone read History of Vaccine Development
by Stanley A. Plotkin?
Sometimes an industry creates a niche market and actively prevents technological or scientific progress in that area.
Needle-less jet injectors have been around since the 1960s, and in the 1970s they were going to Make Hypodermics Obsolete. Sounds like they have a built-in risk of cross-infection and so have been largely abandoned (though the Goofle informs me that the FDA has approved one such device for administering a flu vaccine).
But the Industry is going to suppress new technology, it is going to have to work harder.
I remember the needleless spray injectors. The US Armed Forces still use them for mass inoculations.
Injecting whatever is on one's skin past it never did sound like a grand idea, adding in cross contamination from other service members, plus whatever else gets picked up by liquid residue on the spray jet, yeah, a real niche market.
It didn't stop Star Trek from sticking with it though. ;)
That last one's probably your doom, Fendelsworth. If you don't remember SPEWS, I do.
Does anyone know why all vaccines don't have an oral variety?
Is there some kind of fundamental reason why intramuscular injections are more commonly used?
Unlike some people here, I don't like to be penetrated.
That's simple, Richard Clarke #85. Digestion.
As in, digesting the proteins, thereby rendering them useless for producing immunity. Add in, the difficulty in presenting those proteins (before they end up being digested) to the immune system so as to trigger an immune response.
Only some vaccines have a live, attenuated virus counterpart. Measles, mumps, rubella, tetanus aren't oral, as none of those infections are orally spread. It's conceivable that hepatitis A might be made into an oral form, just maybe, as we don't want to give the infection to someone that we're immunizing someone against.
And no, I'm not big on being penetrated, but I also loathe getting a disease that I could trivially avoid by taking a vaccine against it.
Indeed, the yellow fever vaccine makes me feel quite ill the very day that I receive it. But, nowhere as ill as yellow fever makes its sufferers.
Trust me, I've treated them.
Richard Clarke also has the distinct stench of socks. It boggles my mind how someone can spend so much time and effort to stay on sites dropping turds.
@Science Mom #87, perhaps, he has no personal life to speak of?
At least, my excuse is, I work at night and work's slow. :)
@ScienceMom
I boggles my mind how you can write for a site with virtually no readership and no original content.
It boggles the mind how you can know the full readership of a site that you do not own and hence, lack the statistics to.
Tell me my IP, since you know so much about other people's sites.
@Wzrd1 Add in, the difficulty in presenting those proteins (before they end up being digested) to the immune system so as to trigger an immune response.
Only some vaccines have a live, attenuated virus counterpart. Measles, mumps, rubella, tetanus aren’t oral, as none of those infections are orally spread
So how is measles spread? Can you introduce an attenuated virus through that same route?
Ah, so you want a spray attack of measles upon the population?
Or are you going to paint it on every available surface? How do you control the dosage of a virus that's attenuated to the point where it cannot reproduce and hence, must have a measured dosage?
Magic?
@Wzrd1
Measles, mumps, rubella, tetanus aren’t oral, as none of those infections are orally spread
How are they spread? Do you know?
Measles, mumps droplet and fomite spread. Rubella, mostly droplets from coughing.
Tetanus, spread from contaminated soil, dust and manure into a break in the skin. That doesn't mean a rusty nail, but a break in the skin, more commonly a puncture wound, such as a splinter.
Oh, got a meeting, once done, gotta take my wife to her surgeon for followup.
Measles: Airborne, spread through an infected person coughing and sneezing.
Mumps: Person-to-person through respiratory droplets, as well as through direct contact with saliva of an infected person. Airborne.
Rubella: Airborne. Transmitted by breathing in droplets that are sprayed into the air when an infected person sneezes, coughs or talks.
Tetanus: A person usually becomes infected with tetanus when dirt enters a wound or cut.
Then why bother commenting under other peoples' 'nyms with your vile filth? Surely you can find healthier outlets for your teenage fantasies.
OK. Now what is preventing attenuated vaccines being atomized up the nose?
This is the natural route of entry, yes?
Is there some esoteric reason why this will not be effective?
So, does that mean that we should administer tetanus toxoid via railroad spike?
Maybe we'll get a vampire to deliver the rabies vaccine.
@Ms. Mia Wallace: The problem is that you need a much larger viral load for the nasal route. And you types are all "too many toxinzzzzz!" The MMR vaccine allows us to give a minimal viral load needed to induce antibodies. And, as we've found from the nasal flu vaccine, at this time, nasal vaccines aren't as effective as injected vaccines.
So would you prefer a much less effective vaccine but no injection? Or a much MORE effective vaccine via injection?