Sunday, February 21, 2016

Engaging with the anti-vaxers

Among scientists and in the media, anti-vaxers have earned a certain reputation. “They just don’t know something, or they’re anti-science, or there’s just something pathological about them,” as Mark Largent, a professor at Michigan State University and the author of Vaccine: The Debate in Modern America, characterized it. There is near-consensus among researchers that widespread immunization is crucial for children and American public health. Yet, according to Largent, 40 percent of American parents have either refused or delayed a recommended vaccine for one of their kids.

The question is: Why?
In Largent’s view, the answer has to do with imbalances of power. Many parents feel helpless and overwhelmed within a dysfunctional health-care system, he argued; on an average vaccine schedule, kids may get up to 25 inoculations in their first 18 months, and up to six in a single doctor’s visit. In interviews with people who seek out waivers in Michigan, he and his colleagues found that vaccine-skeptical parents show “tremendously high trust in medical communities,” he said. “Who don’t they trust? The feds, and pharma.” This research, along with rhetoric from recent political fights, suggests some parents may feel uncertain about vaccines partly because they’re skeptical of pharmaceutical companies, whose profit motives mix with their vaccine-promotion campaigns. And while state governments can mandate immunization, this may end up pushing parents away from the public-school system if they feel that regulations are forcing them to make certain decisions about their children’s health…
But as Largent said to a room full of scientists during the annual meeting of the American Association for the Advancement of Science this weekend, “You need to understand your own position. You think you do, but unless you’ve done a tremendous amount of psychotherapy, you really don’t.”
“You are an intensely privileged group of people. You receive tremendous amounts of funding from the economic system, from the political system. You are revered. You have more cultural, social, and economic authority than probably any other group as a group, besides some very, very, very wealthy people. You guys are it. You possess the wheel of the largest and most powerful institution that’s ever existed—that’s modern science.
You’re the hegemon. When you forget that and think, ‘Oh, I’m just this embattled scientist, constantly under fire,’ it’s like, yeah, I understand that you’re being harassed, but it’s because you have so much power and authority.”
To put it another way, doctors and medical researchers have a lot of control over what happens to people’s kids. These scientists have training and expertise that’s inaccessible to the general public, and the way they use their knowledge can define a child’s health and life. Faced with this imbalance of power and information, who can blame parents for being nervous and striking out on the Internet for a second opinion?...
On average, immunization opponents are relatively well-educated, upper middle class, Protestant, and married. Protests and public opposition tend to be led by mothers, rather than fathers. And they’re often relatively older parents—those over 40 tend to be particularly concerned about the possible effects of vaccines, according to Largent.
All of this matters for shaping public policy. State governments, health departments, and researchers have tried various approaches, including all-out bans on non-medical waivers, as in California, or alternative modes of counseling—showing parents gnarly pictures of kids with the measles, making conversations on vaccines more consultative, that sort of thing. All of these approaches have their downsides, but Largent pointed to one glimmer of success. In Michigan, the number of non-medical vaccination waivers reportedly fell by 39 percent in 2015, following a new mandate requiring parents to go through one-on-one counseling sessions with a county official before they can get an exemption. Most parents who go through the counseling don’t change their minds, he said; the difference comes from those parents who don’t bother attending the sessions. Largent believes this success is a result of compromise: Passionately anti-vaccine parents feel like they have a way out of immunizing their kids, but the state has an effective way of discouraging less dogged parents from opting out. And knowing who parents trust matters. That’s why, he said, public-health organizations “have to decouple vaccine efforts from pharmaceutical companies. I don’t want Merck talking about the value of vaccines. Just be quiet. Stop putting Pfizer on your board when you’re doing a local vaccine effort.”
Empathizing with vaccine-skeptical parents is not the same as equivocation. From a public-health standpoint, parents should get their kids immunized against diseases. But Largent’s argument is that public-health efforts are more humane, and likely more effective, when they’re undertaken with an eye toward the feelings of powerlessness that can come along with these kinds of medical decisions.
“Vaccinology has nothing to learn from anti-vaxers,” Largent said to me after the session. “But medicine is an art, not a science. Engaging with anti-vaxers may help you understand how to do medicine better.”


  1. A recent study from California confirms what earlier reports have suggested: that the newer pertussis vaccine, reformulated to be safer and have fewer side effects than the older version, just isn’t as effective.

    The study, by researchers at Kaiser Permanente’s Vaccine Study Center in Oakland, Calif., found that just three years after vaccination with the new vaccine and booster, teenagers had lost virtually all of the vaccine’s protection, and more than 90 percent were susceptible to infection. The teenagers had received only the newer form of the pertussis vaccine and booster, a form without whole cells called DTaP, which in the 1990s replaced the previous vaccine, a whole-cell pertussis vaccine called DTwP. (The pertussis vaccine is given in combination with those for diphtheria and tetanus.)

    These teenagers had the highest incidence of pertussis of any age group in 2014, despite receiving boosters at ages 11 to 12. The booster was introduced in 2005 when health experts realized the new vaccine was not conferring lifelong protection, officials with the Centers for Disease Control and Prevention said.

    But the study showed that even with the booster, teenagers were still vulnerable to infection.

    “The new vaccine provides reasonable short-term protection during the first year, but the protection wanes over the next few years, and not much remains by about three years after vaccination,” said Dr. Nicola Klein, a director of the Kaiser Permanente Vaccine Study Center and lead author of the study, published in Pediatrics earlier this month.

    Pertussis had never been eradicated. Having the disease does not confer lifelong immunity. But the last time there were more than 40,000 infections in the United States was in 1959. That was down from a high of more than 265,000 infections in 1934. By 1976, the number was down to 1,010 infections in the entire country.

    “The levels at which it’s occurring now haven’t been seen in at least 50 years,” Dr. Klein said.

    “The biggest driver is waning immunity from our vaccines,” said Tami Skoff, an epidemiologist with the division of bacterial diseases of the C.D.C. “The protection doesn’t last as long as we originally thought it would.”

    Despite concerns about the effectiveness of the new vaccine, there are no plans to return to the old one. The earlier vaccine carried a high risk of alarming but temporary side effects like pain, swelling at the site of the injection and fever, as well as more serious complications like febrile convulsions or loss of consciousness, said Dr. James D. Cherry, professor of pediatrics at the David Geffen School of Medicine at U.C.L.A., who has written extensively about pertussis. There had also been cases of a brain disorder, encephalopathy, after vaccination...

    That does not mean you should skip vaccinations — on the contrary: Experts say vaccinations are more important than ever for children, pregnant women, and adults generally, especially those who will be in close contact with a newborn, such as grandparents, siblings or a nanny.

    Pregnant women should be vaccinated during the third trimester, the C.D.C. says, even if they have been immunized before. That way, they can develop antibodies that are passed on to the fetus through the placenta. The ideal time for mothers to get the shot is the 27th to 36th weeks of pregnancy; the protective antibodies are highest two weeks after the vaccination.

    For adults, even if the vaccine does not prevent disease entirely, it reduces the severity.(continued)

  2. (continued)That is important, Ms. Skoff said, because the disease — which once killed thousands of Americans each year — can be miserable and prolonged. It can last for months and is often called the “100-day cough.”

    “It’s a very painful disease,” said Dr. Carrie Byington, a professor of pediatrics at University of Utah who heads the American Academy of Pediatrics’ committee on infectious diseases. She had pertussis herself when she was a young doctor. “It’s not like any other cough you’ve experienced. Even as an adult, you can’t really control it. It’s incredibly powerful.”

    A severe infection may require hospitalization, and recovery can take months; the illness can have a lasting effect on lung function, leaving people with shortness of breath or fatigue. Even after a person recovers, another viral respiratory infection can cause pertussislike cough spasms, doctors said.

    For now, however, the focus is not on developing a more effective vaccine. Instead, public health officials are promoting vaccinations for pregnant women and adults. Some experts have suggested more frequent vaccinations for everyone, timed before an expected outbreak, or every three years.
    Courtesy of a colleague