Six Reason to Question Vaccinations

[Ivor the Engineer]

But, Ivor, you have been telling all of us to risk letting our kids die of a vaccine preventable disease because you personally judge the cost per life saved to be too high.

Some risks are so small that they become matters of personal choice. What I find bizarre is why parents who think letting a child risk having a common but mild, or very rare but severe disease is now being thought of in the US as something akin to neglect.

 

[Skeptic Ginger]

Some risks are so small that they become matters of personal choice. What I find bizarre is why parents who think letting a child risk having a common but mild, or very rare but severe disease is now being thought of in the US as something akin to neglect.

Again your perception of the risks differs from mine and many others.

You talk about my statements of fact regarding morbidity and mortality and here you are using inaccurate statements which downplay the risks.

"common but mild" - No, with varicella, that is not accurate. Those cases in which children fully recover from are not always "mild".

"very rare but severe disease" - Ignores the mortality altogether and says nothing about permanent impairment.

"something akin to neglect" - Again, not true, but even if it were, it ignores the impact unvaccinated children have in transmitting the infection to those who do not respond to or are too young to have vaccines themselves.

 

[Skeptic Ginger]

Yes. All health care is, even in the US. It's just that the NHS makes it explicit. I was reading this over the weekend. If you haven't got time to read all 5 sections, sections 2, 3 and 4 are the most thought prevoking.



Actually, there's been a call to do just that. The prospects for an infant born that early are not very good, even if it does survive.

Both you and JS misunderstood my comment about health care rationing. Of course it is rationed in the US, it is rationed by one's ability to pay.

If you are going to take the purely cost/benefit approach and ignore the value of a child's life then simply choosing those measures which you have an issue with is not the way to decide what health care to pay for and what not to pay for. If you analyzed all the things we pay for, why single out vaccines? If you think 24 week gestation babies are not cost effective to treat, then what about 26 weeks? They still cost millions. What about putting 95 year olds in intensive care? The list is endless. Your obsession with vaccines is misplaced.

 

[Ivor the Engineer]

Again your perception of the risks differs from mine and many others.

You talk about my statements of fact regarding morbidity and mortality and here you are using inaccurate statements which downplay the risks.

"common but mild" - No, with varicella, that is not accurate. Those cases in which children fully recover from are not always "mild".

Strangely, it was considered accurate in the vast majority of cases (99.5%-99.9%) before a vaccine was available

"very rare but severe disease" - Ignores the mortality altogether and says nothing about permanent impairment.

What do you think "severe disease" means?

"something akin to neglect" - Again, not true, but even if it were, it ignores the impact unvaccinated children have in transmitting the infection to those who do not respond to or are too young to have vaccines themselves.

In the case of meningitis, they have virtually zero impact. In the case of chickenpox, they are putting other non-immune children at risk of a 0.1% chance of a serious complication, or a 0.001% chance of death.

 

[Deetee]

Let's look at prevnar's track record so far. Remember, it was approved, in 2000, recommended in 2001, but there was a shortage through most of that year, and in 2002 uptake was still at 40%, but it's pretty darn high now. (80%?)

http://www.cdc.gov/ncidod/dbmd/abcs/survreports.htm
The numbers kind of speak for themselves.

Indeed they do.
But I can be as selective with my viewing of this data source as you can.

Look at the bottom of every page from the CDC reports and you will see a little figure representing what the CDC project will be the burden of invasive pneumococcal disease nationally in the age group <5yrs given as cases per 100 000 population.

It goes:

|1997|1998|1999|2000|2001|2002|2003|2004|2005|2006
<5years|76.4|87.6|87.4|71.8|38.9|23.2|22.8|20.8|21.2|20.1

Notice something?
See how from 2002 the rate drops to a quarter of the rate before 2002?
I wonder why that could be....

These figures suggest that from 2002 to 2006, vaccination may have prevented 696 thousand cases of invasive pneumococcal infections in the under 5 population of the USA.
(Calculation based on mean reduction of 58 cases/100 000 population annually [a drop from 80 to 22], population of USA = 300 million)

 

[Deetee]

Yes. All health care is, even in the US. It's just that the NHS makes it explicit. I was reading this over the weekend. If you haven't got time to read all 5 sections, sections 2, 3 and 4 are the most thought prevoking.

Thanks, Ivor - interesting stuff (but rather mathematical).

A comment on risks -I agree with you that we do not need the equivalent of a vaccination gestapo, where encouraging people to do what may be a reasonable thing to do should not be pursued overly aggressively. I still believe in personal choice.
As the more problematic preventable infections are dealt with by way of vaccination, researchers and vaccine developers have looked at more and more moderate/minor infections to tackle, or infections which although rare can have devastating consequences (cervical cancer, hep B and liver cirrhosis and cancer e.g.)

So now we have things like chickenpox vaccine. What next? Vaccines against parvovirus, HHV-7, coxsackie virus, glandular fever? One could construct a valid theoretical argument for vaccinating against all of these (were a vaccine available), but would it be:
(a) in the individual's best interests, or
(b) in society's overall interest public health-wise, or
(c) make sense from a health economy perspective?
The answers to these questions may not always be clear, and they may be in conflict with each other.

 

[Ivor the Engineer]

Both you and JS misunderstood my comment about health care rationing. Of course it is rationed in the US, it is rationed by one's ability to pay.

It's rationed by a lot more than just one's ability to pay, but that's a different discussion.

If you are going to take the purely cost/benefit approach and ignore the value of a child's life then simply choosing those measures which you have an issue with is not the way to decide what health care to pay for and what not to pay for. If you analyzed all the things we pay for, why single out vaccines? If you think 24 week gestation babies are not cost effective to treat, then what about 26 weeks? They still cost millions. What about putting 95 year olds in intensive care? The list is endless. Your obsession with vaccines is misplaced.

I'm only focusing on vaccines because this thread is about vaccination. I started a thread a few weeks ago about the mass prescription of statins which I think is a false economy and ethically dubious. Not surprisingly I was accused of hating fat people.

It's not even vaccination per se that I'm questioning, it's the tactics used to get vaccine compliance and the cost effectiveness of some of the newer vaccinations.

For example, this is the Q&A leaflet for the catch-up pneumococcal vaccination for young children:

What is pneumococcal infection?

Pneumococcal infection can cause pneumonia, septicaemia (bloodpoisoning) and meningitis. Children under two years of age are particularly at risk from this infection. The UK’s routine immunisation programme now offers protection against this infection. Because your child is under two, he or she is being offered this vaccine (PCV). Children over one will only need one dose of the vaccine. Children under one will be offered two doses.

...

Does my child have to have the PCV vaccination?

In the UK, parents can decide whether to have their children immunised or not. PCV is strongly recommended as it will offer your child important extra protection against serious diseases.

It makes it sound like my child is at quite a high risk and this vaccine is the bees knees. But when you look at the actual numbers...

http://adc.bmj.com/cgi/content/full/88/10/859

Background: It is likely that disease specific infectious morbidity is under-reported. Microbiologically identifiable diseases may be "hidden" in ICD-10 code as "unspecified" disease.

Aims: To estimate the proportion of "unspecified" morbidity of infectious cause in infants and young children reported by Hospital Episode Statistics (HES) in England in 1999 that could reasonably be attributed to Streptococcus pneumoniae, and to calculate what number and proportion of diseases could potentially be prevented by a programme of pneumococcal conjugate vaccination.

Methods: Proportions of HES "unspecified" septicaemia, meningitis, and pneumonia attributable to pneumococcal infection were estimated by applying theoretical rates obtained from studies using highly sensitive diagnostic tests. The numbers obtained were added to those coded as pneumococcal in origin. The vaccine preventable proportion was then calculated using serogroup coverage, disease specific efficacy, and vaccine uptake.

Results: For infants and children 3 months to 5 years of age in 1999, HES reported 134, 245, and 216 episodes of pneumococcal septicaemia, meningitis, and pneumonia respectively. In addition, 68, 36, and 2548 episodes of "unspecified" disease respectively are probably pneumococcal in origin. For hospitalisations in England in this age group, 157/202 (78%) cases of pneumococcal septicaemia, 218/281 (76%) cases of pneumococcal meningitis, and 452/2764 (16%) cases of pneumococcal pneumonia may be preventable annually by means of pneumococcal conjugate vaccination.

Conclusions: Paediatric hospital morbidity in England due to pneumococcal septicaemia, meningitis, and pneumonia is under-reported by 34%, 13% and 92% respectively. A larger proportion of morbidity is preventable than implied by ICD-10 code alone.

...the diseases are rare and the vaccine moderately effective.

Why not just tell people the truth? If healthcare providers behave like double-glazing salesmen, people will treat them like double-glazing salesmen.

 

[kellyb]

Indeed they do.
But I can be as selective with my viewing of this data source as you can.

Look at the bottom of every page from the CDC reports and you will see a little figure representing what the CDC project will be the burden of invasive pneumococcal disease nationally in the age group <5yrs given as cases per 100 000 population.

It goes:

|1997|1998|1999|2000|2001|2002|2003|2004|2005|2006
<5years|76.4|87.6|87.4|71.8|38.9|23.2|22.8|20.8|21.2|20.1

Notice something?
See how from 2002 the rate drops to a quarter of the rate before 2002?
I wonder why that could be....

These figures suggest that from 2002 to 2006, vaccination may have prevented 696 thousand cases of invasive pneumococcal infections in the under 5 population of the USA.
(Calculation based on mean reduction of 58 cases/100 000 population annually [a drop from 80 to 22], population of USA = 300 million)

How could you get an actual three or fourfold reduction in invasive disease and no change in death from invasive disease?

There are mild cases of bacteremia and pneumonia, and with bacteremia, it can be a brief, transient kind of thing.

You mistakenly compared the percent of invasive disease which occurred as meningitis, not the rate of meningitis in each year. I think if you did a more careful analysis of those percentages you'd probably find they were not statistically significant but that is a guess on my part. In any case, you really goofed on this one. Not that I expect you to acknowledge your error.

Oops...you're right about the % presenting as meningitis. I was looking at the " * " thinking it was per 100,000 like the cases broken down by age.

The vaccine may be allowing strains to grow which the vaccine eliminated strains had been suppressing, but those strains are weaker, not stronger. If they were stronger then they should have been more invasive regardless of the competition.

That's not true.
A strain can lack the ability to out-compete other bacteria, thus lack abilities to colonize in large numbers for long periods of time, and still be more inclined to cause invasive disease than strains that are more common as causes of invasive disease presently.

In your citation above, remember, there were additional serotypes of pneumococcal bacteria, not some alternative organism so your concern about the pneumococcal bacteria competing with staph bacteria is moot in that case.

But it's still a important part of the overall picture of the impact prevnar has on invasive bacterial disease.

 

[Beth]

I can understand your underlying premise because I have a similar one when I look at corporate America and especially the Bush crony tradition. However, my experience in the health care profession leads me well away from lumping these professionals into the greedy corrupt corporate group. There are some corporate actors who are not greedy and corrupt. But in the scientific and health care professions it is the rule not the exception.

I do NOT start with the assumption that health care professionals are greedy and corrupt, at least no more so than normal and quite possible less so. I simply start with the assumption that they are human beings subject to the same failings as are all human beings.

I do not find the quoted statement of much value. Such statements were in place when I did my research. They do NOT compensate for a committee filled with people who all share the same bias. While I recognize the necessity that drives the waivers, I also recognize the common human failing of bias towards one's own position. The conflict of interest disclosures are part of the legal requirements for the position because the effect of such biases are well-established and documenting them allows citizens, such as myself, to take into account such biases when evaluating the policies developed by such committees.

If the CDC and ACIP want to regain the trust of parents like myself, they are going to have to move beyond words and take actions that reduce or eliminate the necessity of having committee members with documented conflict of interest as part of the decision making process.

 

[Belz...]

Strawmen. As if. You clearly have no idea how it really works.

If you don't care about children and other susceptible folks, then that's your decision. Health care professionals are to be commended on lives saved in the simplest, most natural, and safest way possible.

Ivor seems to think those lives are just numbers.

 

[Belz...]

Why focus on guns? Motor vehicle accidents kill more people. Let's not vaccinate any kids because guns and cars kill more of them than infections. And don't bother with that smoke alarm battery either. Why pay for a smoke alarm battery when cars kill so many people.

Your risk perception is bizarre.

You know, drowning precautions are very important for all parents. So are proper seat restraints, smoke alarms with good batteries, carbon monoxide detectors where heaters or other appliances which use fire are in use. There are many many things everyone should do to protect their children. I am often amazed at how few parents really understand that concept.

Of course, all of Ivor's numbers are based on the fact that we DO take those precautions.

 

[Ivor the Engineer]

Ivor seems to think those lives are just numbers.

Perhaps it's because the rationing in the US isn't as explicit as it is in the UK that many of you think I don't care about children (or people in other age groups) dying?

The fact remains there is a finite amount of money put into the NHS each year, and it is only sensible to try to reduce the rate of mortality and morbidity by the maximum amount possible with the money available. At the same time, resources need to be divided equitably between various groups in society that use the health service, based on what people would like the health service to provide. These are often conflicting objectives.

This report has looked again at the cost-effectiveness of the meningitis C vaccination campaign in the UK using recent data, including herd immunity. It indicates that one of the more optimal ways to use the vaccine was to give 1 dose at 12 months, rather than a dose at 2, 3 and 4 months (3 doses) as is done at present. Adding a catch-up campaign for those younger than 18 years was expected to cost less per quality-adjust-life-year (QALY) gained, though obviously increasing the net cost of the campaign substantially (£230 million rising to to £322 million, giving £/QALY's gained of £3653 and £2760 respectively).

The important thing to note is that this vaccination campaign costs more money than it saves. I.e. it has been introduced to relieve suffering, not save money. The current vaccine campaign, giving a dose at 2, 3, and 4 months has a net cost of £805 million. That's £805 million that can't be spent on cancer treatments, heart disease, new equipment, hospital wards, more nurses or doctors, etc. By targeting the vaccine more effectively, this cost can be more than halved, releasing that money to be spent on more health care.

 

[Eos of the Eons]

Your uninformed blathering does not include a cost anylysis on how much money vaccines save by keeping people healthy. You can go on and on, but that doesn't make you right. The actual money saved is far more because less is spent on treating those that would otherwise be sick, costing companies and parents money by staying home sick or taking care of the sick. Not to mention the cost of burying dead people, and the people left behind with less resources because a spouse is no longer around to help with costs of living, etc.

Companies who offer the vaccines free take into account the cost of sick employees. It's far cheaper to get the vaccines and to have the people not get sick.

 

[JJM]

This is why one does not consult engineers (real, or imagined) on health care.

 

[Eos of the Eons]

I just don't understand why Ivor is trying so hard? Just trying to win an argument? I don't get it.

There are so many variables to consider, and to leave out such obvious ones boggles the mind.

Why are you so fixated on putting down vaccines lately Ivor?

 

[Ivor the Engineer]

Your uninformed blathering does not include a cost anylysis on how much money vaccines save by keeping people healthy. You can go on and on, but that doesn't make you right. The actual money saved is far more because less is spent on treating those that would otherwise be sick, costing companies and parents money by staying home sick or taking care of the sick. Not to mention the cost of burying dead people, and the people left behind with less resources because a spouse is no longer around to help with costs of living, etc.

Companies who offer the vaccines free take into account the cost of sick employees. It's far cheaper to get the vaccines and to have the people not get sick.

Have you even looked at the study I linked to? It certainly doesn't sound like you have. If you do, you will notice that the figures I quoted were net costs, taking into account such things as the cost of treatment.

 

[Eos of the Eons]

Of course I looked at it.
They finally include one variable they've been leaving out:

The authors found that including herd immunity improved the average cost-effectiveness ratio in all cases

They also say that not looking at all of the variables will cause people to miss all the information needed when considering the cost-effectiveness of vaccination. This was my point too. Did you read it?

I'm still more worried about variables you yourself do not consider, rather than what studies do or not.

Are you going to answer my other question?

 

[Ivor the Engineer]

I'll answer your question in about an hour. Stuff to do

 

[Ivor the Engineer]

Of course I looked at it.
They finally include one variable they've been leaving out:



They also say that not looking at all of the variables will cause people to miss all the information needed when considering the cost-effectiveness of vaccination. This was my point too. Did you read it?

Yes, I read it, cover to cover. If you look at Table 1 on page 4 of the full-text article (link at top-right of page), you will see that they included the cost of hospital admission, ICU, treating sequelae, outbreak control, etc. Tables 4 and 5 are also good summaries of the net costs of various vaccination strategies.

I'm still more worried about variables you yourself do not consider, rather than what studies do or not.

Which ones would they be? Children in pain and dying? Do I really need to explicitly state that I do not like the idea of children suffering? The thing is, I don't like the idea of anyone suffering. Which would you choose: save 10 children dying of meningitis or 50 hip replacements? I also don't like people being coerced with over-blown statements of risk, half-truths and sanctions.

Are you going to answer my other question?

Yep.

I just don't understand why Ivor is trying so hard? Just trying to win an argument? I don't get it.

I'm not trying to win an argument, I'm thinking of reasons why some of the more recent vaccines appear to give little return in reduction of mortality and morbidity for their cost.

There are so many variables to consider, and to leave out such obvious ones boggles the mind.

Which ones am I leaving out? If you're talking about my back-of-a-fag-packet calculations, they were just to get a ball-park figure for the risk levels and costs. Clearly, studies like the one I linked to are required to get more accurate estimates in practice.

Why are you so fixated on putting down vaccines lately Ivor?

Not all vaccines, just some of the newer ones for very rare but serious, or very common but (more often than not) mild diseases.

As to why, firstly it is because I doubt that the amount spent on them by the NHS provides particularly good value (i.e. lives saved and disability reduced) for the money. The proposed scheme for the Men. C vaccine (giving only 1 dose at 12 months + catch-up to 18-years) appears to be much more cost-effective. To save an extra few lives, enormous amounts of extra money need to be spent - money that could be used elsewhere in the NHS saving many more lives.

Secondly, there appears to be a good deal of misleading information about the risks of some of diseases the vaccines protect against and their performance from public agencies. E.g., 1 in 330 deaths from measles, or the pneumococcal vaccination just clearing the way for other bacteria to cause problems. This gets right down to the patient, where parents are scared into having their children vaccinated, or not told the whole story about the efficacy of the vaccine. I believe the argument for vaccination would be stronger if a more balanced argument was presented. Don't you distrust sales pitches that make the desired behaviour seem more significant than it really is?

Thirdly, the situation in the US, where a long list of vaccinations is required for a child to go to school is, IMO, ethically wrong. I could maybe understand a sub-set of the list, but many of the vaccines protect against diseases that are not particularly contagious.

 

[JJM]

{snip} Thirdly, the situation in the US, where a long list of vaccinations is required for a child to go to school is, IMO, ethically wrong. I could maybe understand a sub-set of the list, but many of the vaccines protect against diseases that are not particularly contagious.

It would be better if your opinion were better informed by facts. Consider the difficulties of people who survive meningitis and are deaf, what number do you assign to that? Vaccine recommendations do involve judgment; I submit that yours is uninformed.