Dec 05 2011

Vaccine Acceptance Still an Issue

Perhaps the weak link in the effectiveness of vaccines is public acceptance. Individual vaccine types vary in terms of their effectiveness, but all are reasonably effective and very safe. Vaccines are, in my opinion, one of the “home runs” of modern medicine – scientists hit upon a way to marshal our own immune systems to make us resistant or even completely immune to certain infectious diseases. The result has been a dramatic decrease in diseases that used to plague humanity, and the complete eradication of one (smallpox).

It is ironic that the greatest barrier to the effectiveness of the vaccine program is public acceptance. Part of the problem is that very high acceptance is needed in order to achieve what is called “herd immunity” – where there is sufficient protection in the population that an infected individual will likely not cause an outbreak.

In the US the numbers are pretty good, and have remained so even through the recent increase in the anti-vaccine movement. About 68% of children complete the full routine vaccination series. Many of the individual vaccines have compliance rates in the 90s (MMR, for example, was 92.1% in 2008). The level required for herd immunity varies, but it is generally around 85-90%.

Acceptance of the flu vaccine in the US is much lower. Last year the cumulative flu vaccine use in the >6 month old population was 43%. Many people feel that the flu vaccine is not necessary, that it doesn’t work, or even that it is not safe. Uptake is slowly increasing – we  are at slightly higher levels this year compared to last year, but there is still a long way to go. The flu vaccine does have the added challenge of matching the strains covered in the vaccine to the circulating strains, so efficacy does vary from year to year, averaging about 50% effective. This year, so far, it seems that the match is a good one. We are nowhere near herd immunity levels with the flu vaccine.

Increasingly parents are opting for alternative vaccine schedule – 13% according to a recent survey.  And yet, there is no evidence that any of these alternate schedules is any safer than the standard schedule, but they are less effective – they leave children vulnerable for longer to vaccine-preventable diseases. Use of an alternate vaccine schedule, in my opinion, represents a fundamental mistrust of the medical system. The vaccine schedule is not arbitrary. It is based upon a careful review of evidence, matching the timing of each vaccine to when it is needed and when the child’s immune system is mature enough to handle it. The need for booster shots is determined by measuring antibody levels in response to vaccination. All this evidence is reviewed by panels of experts to determine the optimal schedule.

In place of this system 13% of parents would rather substitute either their own judgment or “Dr. Bob’s Alternative Vaccine Schedule.” They apparently buy into the notion that some lone maverick is better able to parse the research than panels of experts.

The historical relationship between vaccine implementation and the reduction of specific infectious diseases is very clear (which does not stop the anti-vaccinationists from denying it). Further, as pockets of vaccine denial are becoming more common, so is the recurrence of vaccine-preventable diseases. Right now Europe is in the midst of a measles outbreak, with more than 26,000 cases, 9 deaths, and 7,288 hospitalizations so far this year. MMR (measles, mumps, rubella) vaccine uptake is lower in Europe than the US. They are also dealing with many immigrant populations with lower levels of vaccine use, so it’s not all vaccine refusal.

This raises another issue with vaccine use – they are very cost effective. In case you haven’t noticed, we are in the middle of a growing health care cost crisis. The cost of health care is a complex issue I cannot get into here – but what is clear is that vaccines are extremely cost effective. In some cases they may even be cost saving – the cost of vaccine is lower than the health costs of hospitalizations they prevent.

Outbreaks of vaccine-preventable diseases are also occurring in the US. Recently there has been an outbreak of whooping cough on Long Island, for example. Whooping cough is a potentially serious illness, especially in infants. Infants are vulnerable until they are old enough to get the vaccine themselves and so depend upon herd immunity.

Often anti-vaxers point out that when such outbreaks occur it is common for most infected individuals to be among the vaccinated. They imply that vaccines therefore do not work. This is also the case with the whooping cough outbreak. This is an abuse of statistics, however.

What is important is the risk of getting the disease in the vaccinated vs unvaccinated populations. With > 90% of the population getting the vaccine the vaccinated population is much larger than the unvaccinated population. Being vaccinated greatly reduces the risk of getting the disease. Also, if someone gets the disease despite being vaccinated they are likely to have a much milder course.

It also should be noted that while overall vaccine rates are high, there are pockets of low compliance (and these are locations where outbreaks are sometimes occurring).

Anti-vaxers often cite the parents’ right to “informed consent” concerning vaccines. I agree – parents should be fully aware of the risks and benefits of vaccines. When informed with accurate information (as opposed to the misinformation from anti-vaxers) the decision to vaccinate should be an easy one.

28 responses so far

28 thoughts on “Vaccine Acceptance Still an Issue”

  1. Jim Shaver says:

    In the US, I think our health care insurers carry some of the blame for some vaccine non-compliance and areas of suboptimal herd immunity. I recently received a TDaP booster from my doctor, which I requested purely from a sense of social responsibility, since it had been more than ten years since I had been vaccinated. (I scraped my leg on some pavement pretty good, which is why the Tetanus shot was already warranted.) My stupid insurance company denied coverage of the Diphtheria and Pertusis portions, due to my age (I’m not a child), so I had to pay the doctor out of pocket.

  2. Draal says:

    Question about the matching the flu vaccine to the strains each year…

    Are there multiple manufacturers of the flu vaccine and are they using the same ‘formula’ so it doesn’t matter which manufactuer’s vaccine is used?

  3. ChrisH says:

    Jim Shaver, that is ridiculous. There is no tetanus vaccine that is not at lease combined with diphtheria!

  4. ChrisH says:

    (erg, I meant “at least”)

  5. Kawarthajon says:

    We have the same problem in Canada. Check out the recent story from Quebec:

    People think: “Measles, no big deal”, but according to the article it is a major contributor to early childhood deaths in the world. The outbreak in Quebec was the largest in the world in almost 10 years.

  6. Jim Shaver says:

    ChrisH, thanks for the feedback. In my experience, when insurance companies deny a portion of a claim, they don’t always make themselves clear with regard to what they are denying and why. So it’s possible that my insurance company only denied the Pertusis portion of the shot, and it’s more than possible that I was confused by their paperwork. But deny they did, and pay I did, and even though it was not a large amount of money, the circumstance still frustrates me. And I think it sends a message to people that this booster is not needed, a message which conflicts with the scientific consensus as I understand it.

  7. Draal,

    The manufacturers don’t choose which strains to include in the vaccines.

    from the CDC web site:

    “The United States Food and Drug Administration (FDA) has chosen the three influenza (flu) viruses for inclusion in the 2011-2012 seasonal flu vaccine based on recommendations from the World Health Organization (WHO). Each year, experts from FDA, WHO, U.S. Centers for Disease Control and Prevention (CDC) and other institutions study virus samples collected from around the world to identify the influenza viruses that are the most likely to cause illness during the upcoming flu season so that people can be protected against them through vaccination.”

  8. ChrisH says:

    I understand, Jim Shaver. I took myself, my then 13 year old daughter and my then 19 year old son in for a flu vaccine about four years ago at a family practice clinic. The insurance company paid for my son and myself, but denied the claim on my daughter. So I had to pay the full $50 for the family practice.

    So the next year we all got them at the local pharmacy for about $20 each. But in the last two years the insurance company has covered all the family practice clinic influenza vaccines for all three of us.

    Insurance companies are flaky like that. Almost twenty years ago they denied coverage for my older son’s four year old well child check, one that included vaccines required by the school district. They claimed that well child checks stopped before age four. But two years later they were all covered for my younger son. Fortunately some actuary made them come to their senses and they now go to age eighteen (which is how I found out about one son’s severe genetic heart condition, which put him first in line for flu vaccines). They did cover my now 17 year old daughter’s influenza and meningococcal vaccines this fall, and if I have to I will pay to get her a third MMR vaccine if she ends up attending UC Berkeley (they had several cases of mumps).

    By the way, I got my Tdap at TAM 9 last summer.

  9. ccbowers says:

    “They apparently buy into the notion that some lone maverick is better able to parse the research than panels of experts.”

    This is certainly true for some, but this statement assuming that all parents know the evidence and recommendations well. Ignorance is still an important factor for many. There are certainly some physician offices that cater to this group, and some parents not knowing the difference, and listen to these “mavericks.” I was surprised to learn that a close friend of mine was veering from the vaccine schedule for his daughter (it was some slight modification that I cannot remember), and when I inquired he said something like “hmm… I’m not sure. We were just going with what our pediatrician told us.” I cannot blame the individual in that circumstance.

  10. ccbowers says:

    Which reminds me… my wife was talking to another friend about her friend’s son who was having diarrhea for a couple of days. Out of curiosity she asked if he was vaccinated for rotovirus. She said that she asked her doctor’s office 1-2 years ago when he was an infant and they said that “they don’t do that” there. Hmm. I would find another pediatrician (not just promoting an altered schedule, but being an obstacle to vaccination).

  11. Roadstergal says:

    Jim Shaver – I wonder if you have a particularly crap insurance company, or if I have a particularly good one? I got a notification about a month and change ago from my provider that it was time for my Tdap booster, and I got it and my flu shot – both covered.

    I encountered my first anti-vaccinationist a year or so ago (sadly, in my own family), and trying to find information on this bizarre movement is what brought me into contact with the skeptical blogs – this one, SBM, the blinking light box, etc. It still absolutely boggles my mind that anti-vaccinationists exist. If there were ever a massive success in modern medicine, it’s vaccines.

  12. jre says:

    I agree with Jim Shaver and others that the benefits conferred by vaccines outweigh their costs by such a large factor that reimbursement or provision without fee ought to be a no-brainer. When I got my TDaP from the Boulder County Public Health office, I was asked why I wanted the booster. I said that it struck me as a civic duty, given that Boulder is a hotspot for pertussis.[1] The staff seemed a bit surprised by my explanation, perhaps because I could have gotten the $16 shot for free if I’d simply said there was a child two years old or younger in my household. On the upside, my getting the TDaP at BCPH meant one more shot was freed up at TAM 9.

    [1] Thanks, Waldorf schools!

  13. ConspicuousCarl says:

    A local clinic looked at me as if I were a nut when I wanted to get a tdap. Even when I explained that my brother just had a baby, the clerks in that backward place still said it was weird.

  14. Kobra says:

    It’s rather tragic, and even appalling, in many cases when children, or even adults for that matter, don’t get vaccinated. At a prominent Florida program, there are many individuals who do not vaccinate which is rather scary. Now I’m not sure if this is because they don’t like pharma or if they have retained mores from their homelands that just don’t jive with western medicine, but either way, it’s disconcerting knowing that these people have no additional immunity to potentially dangerous and deadly heebeejeebees.

    In the end however, I think it’s quite clear that most Americans that do not vaccinate have an underlying agenda against big pharma along with a strong disdain for their methods. I had to even question Medscapes 1-2-3 punch of HPV vacc articles now saying young boys need to be vaccinated and that there may be a link between HPV and MIs. While I assume that all of us posting here are pro-vaccine, I would at least hope that most of us skeptics and critical thinkers actually take the time to take a step back and look at the news and research objectively.

  15. ChrisH says:

    I would at least hope that most of us skeptics and critical thinkers actually take the time to take a step back and look at the news and research objectively.

    Well, I have. I noticed that UC Berkeley had a an outbreak of mumps. Did you?

    I also believe John Salamone has done much more for vaccine safety than Barbara Loe Fisher. I also know the difference between the various mumps vaccine strains that are in use, and that one researcher did not control for the various types of MMR vaccine in a small case studies. And instead of questioning Medscape, I actually know how to look for the original paper in PubMed and know how to get the paper.

    So what exactly do you mean?

  16. Kobra says:

    You would have found the meaning if you had worked on reading rather than the sarcasm. I’m pro-vaccine as it’s very succintly implied in my post, so I’m not sure what’s with the aggressive sarcasm.

    I read the studies because I had been curious about them at the time. My implication was that several emails came out as clusters which made me more suspicious that there was a push by Merck rather than an objective stance by the medscape folks. It’s kind of like those idiotic healthcare reform articles that have permeated through the NEJM with why need the current president’s healthcare ideology. I bet you also think the AMA actually protects physicians ya? Either way, seeing as how you were incapable of deriving my stance on vaccinations, your reply warrants no further response.

  17. ChrisH says:

    I bet you also think the AMA actually protects physicians ya?

    Where did I say anything about that? I suggest you stay away from open flames with that kind of straw man.

    How do you know that Kuo and Fujise were paid by Merck for their research?

  18. Kobra says:

    You didn’t–I just reciprocated the idiocy of your first reply. In other words, I returned the sarcasm and stark assumptions.

    You still don’t get it. I wasn’t suspicious of their research, I was suspicious of the ‘cluster of emails’ that came at once discussing youth female hpv followed by another email discussing youth male hpv followed then by another email discussing hpv and an MI link. This piqued my suspicion. And like any other manuscript, disclosures are available clearly for everyone to see.

  19. ChrisH says:

    Dude, what should have piqued your suspicion were the comments from Muhlestein:

    However, in an accompanying editorial, Muhlestein called the findings hypothesis-generating, citing various limitations, including the use of self-reported MI and stroke, the generally young age of the women, the cross-sectional design, and the lack of adjustment for socioeconomic status.

    Though, since you did not provide a link, I used this one. If you have a different one, you should actually provide it when you comment.

    By the way, did you notice how many times HPV was mentioned in Dr. Novella’s essay? I don’t see it. I noticed he wrote about the return of diseases like measles and pertussis, and some about the uptake of influenza vaccine. I believe one of these has come up from under a bridge.

  20. Amy(T) says:

    @ Jim Shaver (and others) my husband asked for the pertussis vaccine this summer, the doc told him it is good to get but probably won’t be covered by insurance and may cost $80. Husband told him “wife says I need it, so I need it”. Guess what? Insurance covered it! I was also covered when I got it right after our baby was born (3 yrs ago; the baby was also covered).

  21. BillyJoe7 says:

    “pertussis vaccine …may cost $80”

    In Australia the pertussis vaccine is free for all children under 5, and for all new parents.
    The cost for everyone else is about $45.

  22. BillyJoe7 says:

    …oops, there is also a free booster dose for teenagers, usually given through public and private schools, and community health centres

  23. jre says:

    So — to follow up on the comments (including my own) referring to various multi-tiered payment schemes, wouldn’t it be better public policy to simply provide vaccines with no fee? Various agencies already do it in cases of obvious need, usually for families of young children. Granted, the benefit/cost ratio is clearly higher in those cases, but the increased expense of covering the public generally would be, I think, partially offset by economies of scale. There would be one fewer excuse not to get vaccinated, and the implicit message would be clear. How about it?

  24. ChrisH says:

    jre, do you mean something like the Vaccines for Children Program, only more universal and also for adults?

  25. jre says:

    Exactly. I see a patchwork of publicly subsidized coverage varying by place and condition, augmented by various voluntary efforts. For example, I give to Every Child by Two, who try to plug the gaps in the public programs, and this year I’ll add the Women Thinking Free Foundation, who sponsored the very successful “Hug Me” clinics at DragonCon and TAM. And I’m wholeheartedly in support of grassroots organizing to promote vaccination. But in the case of pertussis, there is a strong case to be made that public health agencies get back the cost of adult vaccination many times in reduced infection, and hence there is no good reason to restrict the free coverage. I don’t begrudge them the $16 — I just want to see the immunization rate go up, and think that there must be some adults who use the cost as an excuse to skip the shot.

  26. perscors says:

    Just saw this weird article floating around the web:
    Do you guys know anything about this?

  27. ChrisH says:

    perscors, um, wow. That is just chock full of every idiotic thing I have read over the past fifteen years. It is a classic case of cherry picking, lying and just general idiocy. The links go to sites like Mercola and childhealthsafety (known for Lies, misrepresentation, and abuse).

    Looking at the ads and other articles in that site, I would hazard a guess that it is not exactly full of real journalists. Dr. Phil Leveque seems like an interesting character. Though it was hard to find anything on him that was not self-promotion.

  28. SAS says:

    Perhaps, as you feel so strongly about the issue, you might help by providing a well referenced table explaining what the known risks are of each vaccination, alongside the benefits (M&M, symptoms, sequelae from the disease) of receiving it, as well as being frank about potential unknown risks of vaccines.

    I hear a lot of ‘noise’ around the autism issue but very little about other concerns such as incidence of allergies, asthma, CFS, autoimmune and inflammatory diseases.

    Nothing in life is black and white.

    The pharmaceutical companies have a well-documented history of fraud motivated by greed. In the last decade alone Pfizer has paid ~$3bn in fines and entered into three corporate integrity agreements with HHS. Drugs and vaccines are rushed through to market and occasionally recalled for safety or concerns over fraudulent research; celecoxib, ziprasidone come to mind. In 2010, Rotarix was recalled after it was found to be contaminated with porcine cirovirus 1 and after it had been administered to around 30 million people. The contamination was only found by accident, by a third party lab, attempting to prove non-contamination of a range of vaccines. 3/8 tested contained foreign viral DNA contaminants.

    Victoria, J., Wang, C., Jones, M., Jaing, C., McLoughlin, K., Gardner, S., & Delwart, E. (2010). Viral nucleic acids in live-attenuated vaccines: detection of minority variants and an adventitious virus. Journal of Virology DOI: 10.1128/JVI.02690-09

    These things do happen. In order to foster an environment where true ‘informed consent’ can occur we need to be upfront about it, otherwise we are no better than those at the other end of the spectrum.

    There are risks associated with whatever decision you make. There’s no point pretending otherwise. Those risks need to be presented in a fair and unbiased manner.

Leave a Reply