autism-vaccine link?

[fls]

Let me make it clear that I think everyone involved in this discussion is thoughtful and intelligent. I find this very interesting because what we see here cannot be dismissed as the result of ignorance or prejudice (the reason one is tempted to use ).

KellyB has done more research than I into how the vaccines actually work, the risks involved, etc. I've learned a lot from both of them.

And yet it has been pointed out over and over again that KellyB draws conclusions that are not supported by the information she presents, that she misunderstands some fairly elementary concepts in the area of vaccine research, and that she misrepresents what the available research actually shows (although, to be honest, I don't think she does it deliberately - I think it's a reflection of the sources she uses). But you seem to have no qualms about accepting the information she presents and the conclusions she draws.

Someone - can't recall who - has recently posted about the problems of different varieties of an illness (was it hepatitus?) emerging such that the total number of cases doesn't reallly change, only the strains of the disease. That was quite interesting.

It would be interesting if there was any research that supported that conclusion. However, as Deetee (and others previously) has already addressed several times, that's not what the research actually shows. I realize that will not change your impression, though - another example of how this isn't really related to information.

Anyway, in a very real sense, none of us ever have the exact same information. I'm a little reluctant to grant that you have more than the others. While I'm sure you have more information on a particular aspect of vaccinations, they may well have more information about other aspects. Which aspects are most important? That's a subjective decision about which reasonable people can disagree.

And that beautifully illustrates the issue. As I have mentioned previously, my graduate work was in public health including economic analysis. My residency and fellowship research was on vaccine policy. And I have years of clinical experience as well as serving in an advisory role when it comes to policy. Skeptigirl has also outlined her extensive knowledge and experience in this area. I'm not sure of all of Deetee's background - I have a vague recollection that he specializes in infectious disease? Neither KellyB nor Ivor have experience in this area, but rather seem to have done some reading from a hodge podge of sources.

I'm not saying this as any sort of appeal to authority. I'm saying this in order to make it explicit that this clearly is not about 'who' knows 'what'. The perception of credibility has almost nothing to do with knowledge. Even the information you used to decide that the ACIP was not to be trusted has nothing to do with advisory committees in other countries or to do with Deetee, Skeptigirl, or me.

I'm not convinced there the problem is a lack of knowledge on the part of those who criticize various aspects of vaccine policy. I certainly agree that there is a barrier related to the difference in attitude when faced with a lack of knowledge, but I see it from the other side. Many medical professionals seem oblivious to their own lack of knowledge regarding the non-medical aspects of medical policy decisions - such as cost-benefit analysis and group decision making processes - and the important role that factors like that can play in making a policy decision.

Cost-benefit analyses, group decision-making processes, as well as other relevant areas of research/understanding, are well-established components of the process of medical policy decisions. I can't speak to what you think your own experience is when it comes to medical professionals, but does that have any relevance here? We obviously aren't talking about them.

If we keep on pretending that this issue has anything to do with knowledge about vaccines or knowledge about who should or should not be considered credible, I think we are missing the boat. On the other hand, I don't really have any good ideas about where to go from here. Unlike Skeptigirl, I am fairly ignorant when it comes to research related to communication.

Linda

 

[Ivor the Engineer]

EotE,

What does it take to be "anti-vaccine"? All I can remember having questions or doubts about are:

1) The efficacy of the seasonal flu vaccination.
2) The effect of the varicella vaccination on the incidence of Zoster and its cost-effectiveness since it has been discovered two (and maybe more) doses are required for long term immunity.
3) The cost-effectiveness of routine use of the Hep A vaccine.
4) The wisdom and ethics of using coercion and positive spin to increase vaccine uptake.

If the above puts me outside the vaccination supporters’ camp in your mind then it must be a very small place indeed. (That’s the camp, not your mind)

 

[Ivor the Engineer]

Linda,

I don't know what you think professional engineers do, but the fundamental skills are exactly the same as those you have gained from your own experience. We have meetings too you know.

Is the Cochrane database a 'hodgepodge' of a source? Is Tom Jefferson talking out of his ass when he questions the effectiveness of the seasonal flu vaccine? Should I only trust sources which agree with your point of view? Have you ever been wrong?

 

[fls]

Linda,

I don't know what you think professional engineers do, but the fundamental skills are exactly the same as those you have gained from your own experience. We have meetings too you know.

Is the Cochrane database a 'hodgepodge' of a source? Is Tom Jefferson talking out of his ass when he questions the effectiveness of the seasonal flu vaccine? Should I only trust sources which agree with your point of view? Have you ever been wrong?

Attend meetings, read Cochrane reviews, assume infallibility? Damnit! I've been going about it all wrong, then.

Linda

 

[Beth]

Let me make it clear that I think everyone involved in this discussion is thoughtful and intelligent. I find this very interesting because what we see here cannot be dismissed as the result of ignorance or prejudice (the reason one is tempted to use ).

Thank you. That is about the only cogent point I've been trying to make - that the criticisms that have been raised should not be dismissed on that basis.

And yet it has been pointed out over and over again that KellyB draws conclusions that are not supported by the information she presents, that she misunderstands some fairly elementary concepts in the area of vaccine research, and that she misrepresents what the available research actually shows (although, to be honest, I don't think she does it deliberately - I think it's a reflection of the sources she uses). But you seem to have no qualms about accepting the information she presents and the conclusions she draws.

No, I don't accept anything I read on Internet posts as being true with corroborating it. I accept her posts much as I do yours: interesting and potentially true. I merely meant that she raises points that I am not equiped to accept or deny without a doing a lot of research myself. You often do the same. As far as the criticisms of her understanding, I'm not equipped to make that call. I can only say that intelligent people who have spent a more time than I have reading the available research disagree on the implications of that research. You criticize her understanding, she criticizes yours. So?

It would be interesting if there was any research that supported that conclusion. However, as Deetee (and others previously) has already addressed several times, that's not what the research actually shows. I realize that will not change your impression, though - another example of how this isn't really related to information.

Actually I found Deetee's posting quite interesting as well. As far as my impression goes of that particular claim, it was formed by posts on this site, not by 'anti-vax liars' because I never bother with their sites. I merely find it an interesting claim. I have not researched it to corroborate either posters claims.

And that beautifully illustrates the issue. As I have mentioned previously, my graduate work was in public health including economic analysis. My residency and fellowship research was on vaccine policy. And I have years of clinical experience as well as serving in an advisory role when it comes to policy.

Actually, no. I don't recall reading about your specific background before. I was aware you were a doctor. That was the extent of it.

Skeptigirl has also outlined her extensive knowledge and experience in this area. I'm not sure of all of Deetee's background - I have a vague recollection that he specializes in infectious disease?

Yes, Skeptigirl makes her expertise in the area quite clear.

Neither KellyB nor Ivor have experience in this area, but rather seem to have done some reading from a hodge podge of sources.

Yes, neither KellyB nor Ivor have invested themselves in promoting vaccines professionally. They are simply interested persons, like myself, who engage in conversation about the issue and they've done a reasonable amount of research for themselves. Yes, professionals have more knowledge and experience. They are also likely to share a particular set of biases on the issue. As professionals working in the field, it's reasonable to suppose that you and skeptigirl either believe in the importance of vaccines or you would have found a different line of work. That doesn't mean your opinions are not well supported, but it does mean that you are far more likely to read and remember information that supports your position than information that doesn't. You are also more likely to accept information that supports your POV and question information that doesn't. That's simply human nature and we all have such tendancies.

I'm not saying this as any sort of appeal to authority. I'm saying this in order to make it explicit that this clearly is not about 'who' knows 'what'. The perception of credibility has almost nothing to do with knowledge. Even the information you used to decide that the ACIP was not to be trusted has nothing to do with advisory committees in other countries or to do with Deetee, Skeptigirl, or me.

Correct. The information I used to decide I couldn't trust the ACIP recommendations didn't have anything to do with their knowledge base as individuals. It had to do with their combined backgrounds and biases combined with my knowledge of how people on committees work together to make decisions and how they can, despite good intentions, arrive at suboptimal choices.

Cost-benefit analyses, group decision-making processes, as well as other relevant areas of research/understanding, are well-established components of the process of medical policy decisions. I can't speak to what you think your own experience is when it comes to medical professionals, but does that have any relevance here? We obviously aren't talking about them.

My experiences with medical professionals and vaccines are that they simply advise parents to follow the recommendations provided by the ACIP. No, I don't think it has any relevance here.

If we keep on pretending that this issue has anything to do with knowledge about vaccines or knowledge about who should or should not be considered credible, I think we are missing the boat. On the other hand, I don't really have any good ideas about where to go from here. Unlike Skeptigirl, I am fairly ignorant when it comes to research related to communication.

Linda

Why do you think the issue of who should or should not be considered credible is missing the boat? To me, that's the main problem. I strongly resent that I cannot trust the ACIP recommendations as being in my families best interests and I'm willing to share that opinion with anyone who asks. What do you think the important issue is?

 

[Ivor the Engineer]

Linda, while I appreciate your wit and sense of humour, the following questions were serious and I'd like sensible answers to them, if you would be so kind. (How am I ever going to learn if you will not teach me?)

Is the Cochrane database a 'hodgepodge' of a source?

Is Tom Jefferson talking out of his ass when he questions the effectiveness of the seasonal flu vaccine?

Should I only trust sources which agree with your point of view?

 

[Skeptic Ginger]

Yes, those are different things. And yet another thing is to recognize that different definitions of evidence are appropriate in different situations. ....

Conclusions are not evidence by any definition, (unless someone's conclusion is evidence about them). Scientific caliber has nothing to do with it. You draw a conclusion from evidence. You can't then define the conclusion as evidence.

You should try to figure out why it is you don't understand this concept rather than continuing to believe it is a matter of opinion.

 

[Beth]

EotE,

What does it take to be "anti-vaccine"? All I can remember having questions or doubts about are:

1) The efficacy of the seasonal flu vaccination.
2) The effect of the varicella vaccination on the incidence of Zoster and its cost-effectiveness since it has been discovered two (and maybe more) doses are required for long term immunity.
3) The cost-effectiveness of routine use of the Hep A vaccine.
4) The wisdom and ethics of using coercion and positive spin to increase vaccine uptake.

If the above puts me outside the vaccination supporters’ camp in your mind then it must be a very small place indeed. (That’s the camp, not your mind)

I second that list and add too many exemptions are granted to members of the vaccine advisor committee with financial ties to vaccine manufacturers.

But in general, I support vaccination programs. I'm thankful to be protected from diseases like polio, whooping couph and dipthera. I've looking into the risk benefit analysis of vaccines and find most unquestionably worthwhile. Your point number 4 I personally give the most weight to. Both tactics, coercion and positive spin to the point of deliberate misinformation make me very wary of trusting the policy recommendations without doing a fair amount of research for each vaccine. Those tactics thus contribute to the credibility problem.

 

[Capsid]

I second that list and add too many exemptions are granted to members of the vaccine advisor committee with financial ties to vaccine manufacturers.

Is your objection to ACIP or to vaccine advisory panels in general? What about those for Europe and Canada? I'm not sure if they come to the same conclusions about all the vaccines, perhaps Europe is delaying about Varicella.

 

[Skeptic Ginger]

Linda, while I appreciate your wit and sense of humour, the following questions were serious and I'd like sensible answers to them, if you would be so kind. (How am I ever going to learn if you will not teach me?)

Is the Cochrane database a 'hodgepodge' of a source?

Is Tom Jefferson talking out of his ass when he questions the effectiveness of the seasonal flu vaccine?

Should I only trust sources which agree with your point of view?

While Linda can answer for herself, I have a couple comments of my own.

The Cochrane data base is often touted as the final word, yet often there are insufficient studies from which the conclusions are based and that is discussed in the data base reports. You have to keep in mind that additional research continues and no one is updating Cochrane after each new study. And even when that isn't the case, there is no guarantee Cochrane has evaluated all the studies that were available at the time of the review. Nor is there a guarantee or consensus that the data base review criteria are beyond reproach. Cochrane is a very useful source of information, but it can mistakenly be given more credence than it warrants.

There has been additional research which has shown the effectiveness of seasonal influenza vaccinations conducted since the Cochrane review of some of the data.

Also, it depends on your outcome measure. If the measure is to prevent influenza, the elderly have milder illness but not as much is prevented. That is the reason for changing strategy and looking at vaccinating children who are the reservoir for influenza during outbreaks. If you look only at death rates over the years and not specifically at influenza, there are many contributing variables that are not sorted out in that particular avenue of research.

I have read the studies and the Cochrane review claiming no effect seen from influenza vaccination. The conclusion is contradicted by many other studies and the consensus among public health and infectious disease practitioners is the research does indeed support influenza vaccine as very important in decreasing morbidity and mortality of influenza disease.

 

[Skeptic Ginger]

[sidetrack]

For those interested, here's the minutes from the JCVI Varicella / Herpes Zoster sub-group:

http://www.advisorybodies.doh.gov.uk/jcvi/mins-varicella-041207.htm

Looks like the cost-effectiveness modelling for the UK is going to assume a 2-dose schedule and a significant increase in the number of cases in Zoster as seen in a couple of studies from the US.

[/sidetrack]

Your increase in zoster studies are a) not exactly overwhelming evidence; and b), zoster is a minor treatable infection unless you are immunocompromised or have corneal involvement and on a scale of 1-10 with 10 being more dangerous, zoster ranks a bout a 2 compared to primary varicella infection. (chicken pox).

 

[Skeptic Ginger]

Note that we've gone from discussing the case to quibbling over basics, like what evidence is.

Sorry, it has to do with a different thread but it is hard to not bring up when the basics of that problem underlie other misconceptions.

 

[fls]

The information I used to decide I couldn't trust the ACIP recommendations didn't have anything to do with their knowledge base as individuals. It had to do with their combined backgrounds and biases combined with my knowledge of how people on committees work together to make decisions and how they can, despite good intentions, arrive at suboptimal choices.

You have described how you determined that the potential existed for sub-optimal choices. Can you tell me how you went on to determine that sub-optimal choices were made?

Linda

 

[Skeptic Ginger]

....
Beth, you are referring I think to the issue of serotype replacement. This happens when strains of the infection that are not covered by the vaccine try and fill the niche left behind as infection rates drop. However, with all the vaccines I know about, the replacement is still a tiny fraction of the previous total. So no, the total numbers of cases are not the same, they are still significantly less. The main vaccine this occurs with is pneumococcal, but it also affects others.

Antivaxers will point to serotype replacement, trying to disguise the actual numbers so that someone with an eagle eye cannot imediately rumble them.

Here is a prime example, quoting word for word the paragraph from the "insideVaccines" blog:.....

I assume a few of you saw this recent health news.

Deadly meningitis strain eliminated in Uganda: GAVI alliance

GENEVA, March 10, 2008 (AFP) - Uganda has virtually eliminated a deadly strain of meningitis thanks to vaccines funded by the GAVI Alliance initiative, the public-private partnership said on Monday.

Hib meningitis (Haemophilus influenzae type b) has been virtually wiped out in the East African country just five years after the vaccine was introduced nationwide, GAVI said in a statement.

Hib kills around 400,000 children under the age of five each year, mostly in the developing world.

"The Ugandan immunisation programme now prevents almost 30,000 cases of severe Hib disease and 5,000 child deaths," the statement said.

Uganda introduced 16.5 million doses of Hib vaccines from 2002 to 2006 thanks to support from the GAVI initiative.

The incidence rate dropped by 85 percent within four years and fell to zero in the fifth year....

 

[Skeptic Ginger]

... Yes, professionals have more knowledge and experience. They are also likely to share a particular set of biases on the issue. As professionals working in the field, it's reasonable to suppose that you and skeptigirl either believe in the importance of vaccines or you would have found a different line of work....

For such a successful profession as modern medicine, it amazes me when people draw a conclusion such as this.

Might it not be just as reasonable that people such as Linda, Deetee and myself take pride in doing a good job? That we take pride in staying abreast of the latest and best information on which to make our practice decisions?

Medicine (and nursing) are difficult professions. When a mistake is made or a failure occurs and one finds out one wasn't aware of some new discovery or research, people can suffer, people can die. How do you think that might affect someone's practice? I'm not in the business of selling anything. I am in the business of providing good medical and nursing care.

Most health care providers (and there are exceptions) are interested in providing the best care, whatever that may be. That means evidence based medicine. If it were more prevalent that providers merely stuck with some dogma they were sold on at some point in school or in their practices, we'd still be draining blood from wrists as the preferred method of treating disease.

 

[Skeptic Ginger]

Is your objection to ACIP or to vaccine advisory panels in general? What about those for Europe and Canada? I'm not sure if they come to the same conclusions about all the vaccines, perhaps Europe is delaying about Varicella.

And regardless of the ACIPs ties to anything, their decisions are made in public hearings and the criteria are laid out as well as the supporting citations in the recommendations. It's pretty hard to bias your decisions in such a glass house.

 

[Ivor the Engineer]

Your increase in zoster studies are a) not exactly overwhelming evidence; and b), zoster is a minor treatable infection unless you are immunocompromised or have corneal involvement and on a scale of 1-10 with 10 being more dangerous, zoster ranks a bout a 2 compared to primary varicella infection. (chicken pox).

...and yet more people are admitted to hospital for Zoster than chickenpox.

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA

We studied the epidemiology of varicella (chickenpox) and herpes zoster (shingles) in The Netherlands to assess the desirability to implement routine varicella zoster virus vaccination in The Netherlands. Data on seroprevalence of varicella zoster virus in the general population (1995-1996), consultations of general practitioners for varicella (2000-2002) and herpes zoster (1998-2001) and hospital admissions due to varicella (1994-2001) and herpes zoster (1994-2001) in The Netherlands were analysed. The seropositivity increased sharply with age from 18.4% for both 0- and 1-year-olds, to 48.9%, 59.0%, 75.7% and 93.0% for 2-, 3-, 4- and 5-year-olds, respectively, and varied between 97.5% and 100% for older age groups. The average annual incidence of GP-consultations amounted to 253.5 and 325.0 per 100,000 for varicella and herpes zoster, respectively. The incidence of hospital admission due to varicella and herpes zoster was 1.3 (2.3 including side diagnosis) and 2.7 (5.8) per 100,000, respectively. Whilst for varicella, the incidence of GP-consultations and hospital admissions were highest in childhood, for herpes zoster, these were highest in elderly. Insight into epidemiology of varicella zoster is needed for the assessment of the desirability of introduction of routine varicella zoster vaccination.

 

[fls]

Why do you think the issue of who should or should not be considered credible is missing the boat? To me, that's the main problem. I strongly resent that I cannot trust the ACIP recommendations as being in my families best interests and I'm willing to share that opinion with anyone who asks. What do you think the important issue is?

I think the issue is that knowledge/information isn't used to determine who should or should not be considered credible, as you have illustrated (depending upon whether you have an answer to the question I asked earlier).

That my husband occasionally travels on business trips by himself and that men sometimes cheat while on business trips does not mean that I have knowledge that my husband is cheating on me.

Linda

 

[Capsid]

...and yet more people are admitted to hospital for Zoster than chickenpox.

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA

Isn't that an argument for the vaccine anyway? If you are immunised against CP then you won't get herpes zoster.

 

[Ivor the Engineer]

Isn't that an argument for the vaccine anyway? If you are immunised against CP then you won't get herpes zoster.

In the long term, yes. In the medium term (over 30 or so years after mass varicella vaccination) the risk is there will be an increase in the number of cases of Zoster because of the lack of boosting from exposure to the wild virus.