Six Reason to Question Vaccinations

[Skeptic Ginger]

...Like I said, this is getting ridiculous.....

Cost benefit, I can discuss. Ivor has a blindspot for the severity of the risk and only sees the frequency but at least he is using some logic. Kelly's misunderstanding of some of the research she reads, I can discuss. Sometimes she actually has a point, other times her game of 'gotcha' gets the better of her and she posts in haste.

But this nonsense. It's like a bunch of fools who think they found the evidence they've been dreaming of for years, evidence vaccines are bad, evil, dangerous things. They've found the key no one in the entire medical and scientific community noticed but them, a clear connection that the US uses too many of those bad, evil, dangerous vaccines.

Good grief!

 

[kellyb]

England must be considering adding the HBV vaccine for children.

There's been talk of it, but it doesn't look too likely:

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=15018847&dopt=AbstractPlus

Incidence and routes of transmission of hepatitis B virus in England and Wales, 1995-2000: implications for immunisation policy.

Health Protection Agency, Communicable Disease Surveillance Centre, Colindale, 61 Colindale Avenue, London NW9 5EQ, UK. susan.hahne@hpa.org.uk

OBJECTIVES: We aimed to describe the current HBV incidence and patterns of transmission in the UK, to estimate the rate of new carrier infections, and to discuss implications for the control of HBV through immunisation

RESULTS: The estimated annual incidence of HBV infection in England and Wales was 7.4 per 100,000

CONCLUSIONS: The incidence of acute HBV infection in England and Wales has remained low, with a similar pattern of reported routes of transmission compared to the early 1990s. The UK prevalence of HBV infection is dependant on global rather than national immunisation policy. Endemic transmission may be reduced by improving immunisation coverage among injecting drug users, which is expected to also reduce the number of cases without a risk factor reported. In addition, immunisation options that better suit the needs of ethnic minorities need to be explored.

 

[kellyb]

Hepatitis A vaccine in this country is only recommended for all kids west of the Rocky Mountains where the incidence of hep A is greater. It is not a routine vaccine for low prevalence states to my knowledge.

The CDC has been phasing universal HepA vaccination in in incremental steps:


http://www.cdc.gov/MMWR/preview/mmwrhtml/rr4812a1.htm

Summary
Routine vaccination of children is the most effective way to reduce hepatitis A incidence nationwide over time. Since licensure of hepatitis A vaccine in 1995, this strategy has been implemented incrementally, starting with the recommendation of the Advisory Committee on Immunization Practices (ACIP) in 1996 to vaccinate children living in communities with the highest rates of infection and disease. These updated recommendations represent the next phase of this hepatitis A immunization strategy. Vaccination of children living in states and communities with consistently elevated rates of hepatitis A will provide protection from disease and is expected to reduce the overall incidence of hepatitis A.

http://findarticles.com/p/articles/mi_hb4384/is_200511/ai_n18900001

ATLANTA -- All children should receive hepatitis A vaccine beginning at age 12-23 months, and the vaccine should be integrated into the routine childhood immunization schedule, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices voted at its fall meeting.

http://www.cispimmunize.org/ill/pdf/HepAAAPPolicy.pdf

In 2005, the US Food and Drug Administration (FDA) changed the youngest approved age of administration of hepatitis A vaccine from 24 months to 12 months of age, which facilitated incorporation of the vaccine into the recommended childhood immunization schedule. As the next step in the implementation of the incremental vaccine immunization strategy, the AAP now recommends routine administration of an FDA-licensed hepatitis A vaccine to all children 12 to 23 months of age in all states according to a CDC-approved immunization schedule.

http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5507a1.htm

In 1999, as the next step in a strategy of incremental implementation of recommendations for routine vaccination of children, ACIP expanded the recommendations to include vaccination of children living in states, counties, and communities in which hepatitis A rates were consistently above the national average (3). Coincident with implementation of these recommendations, hepatitis A rates have declined to the lowest level ever recorded (4). Because declines were largest in the areas in which routine vaccination of children was occurring, rates are now more equivalent across regions, with the highest rates occurring among children in parts of the country where vaccination has not been recommended (5). This statement includes recommendations for the final step in this incremental strategy, routine hepatitis A vaccination of children nationwide.

 

[Eos of the Eons]

SO?

 

[kellyb]

Who here's up to date on their hepA shots, just out of curiosity?

ETA:

Some HepA info on Canada vs. The US:

Hep A rates in Canada over the years
http://www.phac-aspc.gc.ca/im/vpd-mev/tables/vpd-hepa-cig2006-lrg_e.gif



http://www.phac-aspc.gc.ca/hcai-iamss/bbp-pts/hepatitis/hep_a_e.html

Canadian Data on the trends of HAV
The incidence of Hep A was approximately 2.9 cases for every 100,000 persons in 1999 (Health Canada, Notifiable Diseases Online)

And in the US:
http://jama.ama-assn.org/cgi/reprint/294/2/194.pdf

Following the nadir
in 1992,rates increased through 1995
(31 582 reported cases; 12.0/100 000),
and then declined steadily.The 2003 rate
of 2.6 per 100 000(7653 reported cases)
is the lowest ever recorded, and is 71%
lower than either previously recorded
nadir (P
.001).

 

[Skeptic Ginger]

Me and my son of course. WA is a high prevalence state.

And I am a frequent traveler to third world countries so I would have wanted to get it in the future anyway.

 

[Skeptic Ginger]

The CDC has been phasing universal HepA vaccination in in incremental steps:

http://www.cdc.gov/MMWR/preview/mmwrhtml/rr4812a1.htm

Just an FYI (because I see the ACIP has expanded their recommendation to include all states), the "incremental steps" noted in this article refers to one age at a time, not one (or more) states at a time. All new vaccines recommended for children are introduced this way in order to not overwhelm vaccine providers and deplete vaccine supplies. In this state, for example, they are only up to 10th grade for hep B being required in school. Next year they will add 11th and the following year 12th.

http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5507a1.htm

You only needed to cite this source. You are talking about official recommendations. The other 2 sources just reflect on this one.

Cost-Effectiveness of Hepatitis A Vaccination of Children

The cost-effectiveness of nationwide routine hepatitis A vaccination was evaluated in an analysis that used a Markov model to follow a single U.S. birth cohort of approximately 4 million persons from birth in 2005 through age 95 years or death. Compared with no childhood vaccination, routine vaccination at age 1 year would result in 183,806 fewer infections and 32 fewer deaths in each cohort (CDC, unpublished data, 2005). The cost-effectiveness ratio was estimated at $173,000 per life year gained and $24,000 per quality-adjusted life year (QALY) gained. Compared with 2003 vaccine coverage levels, the incremental cost-effectiveness ratio of routine nationwide vaccination at age 1 year was $73,000 per QALY gained. When out-of-cohort herd immunity was taken into account, vaccination at age 1 year yielded a societal cost of $1,000 per QALY gained. Another economic analysis that included the estimated reduction in secondary cases among household contacts of infected children yielded similar results (196). ...

... Preexposure Protection Against HAV Infection

The following recommendations for hepatitis A vaccination are intended to further reduce hepatitis A morbidity and mortality in the United States and make possible consideration of eventual elimination of HAV transmission. Hepatitis A vaccination is recommended routinely for children, for persons who are at increased risk for infection, and for any person wishing to obtain immunity.

And now that the ACIP supports expanding the program to all states each state which hasn't already added the vaccine to the school requirements will likely do so.

More fuel for Ivor's fire.

 

[kellyb]

Just an FYI (because I see the ACIP has expanded their recommendation to include all states), the "incremental steps" noted in this article refers to one age at a time, not one (or more) states at a time.

So when they said:

Routine vaccination of children is the most effective way to reduce hepatitis A incidence nationwide over time. Since licensure of hepatitis A vaccine in 1995, this strategy has been implemented incrementally, starting with the recommendation of the Advisory Committee on Immunization Practices (ACIP) in 1996 to vaccinate children living in communities with the highest rates of infection and disease.

They really meant "incrementally by age"...not incrementally by area?

 

[Skeptic Ginger]

So when they said:


They really meant "incrementally by age"...not incrementally by area?

Well, let's see. I could do what you did after missing the fact the overall incidence of invasive pneumococcal disease went down when you posted about the vaccine making things worse and just not answer this.

Or.., I could just say, hmm, upon looking further at that citation*:

To achieve these goals, hepatitis A immunization strategies have been developed and implemented incrementally, on the basis of the characteristics of hepatitis A epidemiology and the feasibility and effectiveness of hepatitis A vaccination. Initial recommendations involved vaccination of persons in populations at increased risk for hepatitis A and of children living in communities with the highest rates of infection and disease.

I see it does refer to incremental populations. It maintains the same meaning whether it is incremental by age group or incremental by risk level, but I see I was mistaken. Except I wouldn't interpret that as adding states. I would interpret it as vaccinating the highest risk groups first, then assessing the results and analyzing the data for the lower risk groups as you go.

(*Note: see sig.)

 

[Tony4245]

Sure, China's health care system is completely unaffected by politics.

I don't know - is it? I know ours isn't.

Apparently you missed the part where the Chinese government refused to acknowledge to the rest of the world SARS was brewing in the months before it spread to other countries.

Actually, no - I didn't miss it. But I'll be quite sure to mention that, when I give my epidemiology lecture to the masters' students on Wednesday.

 

[Deetee]

Who here's up to date on their hepA shots, just out of curiosity?

My family all had vaccine shots this year. We travel abroad (outside the UK) often enough to justify it.
I am vaccinated to my eyeballs because of my (medical) work - this includes Hep B, annual flu, smallpox.
If any of my kids really gets the travel bug, vaccinations will include whatever is appropriate, including Hep B. I will want my daughter to get HPV vaccine, and when a herpes vaccine is available I guess they will have that too.

Only about 5 people die in the UK each year from malaria. A standard course of malaria chemoprophylaxis for travellers costs about £40 (it is not "free" on the NHS).
With a "risk-benefit" ratio as low as this, I suppose some people here will not want to bother taking prophylaxis for their safari trip to Kenya.

 

[Capsid]

I'm up to date on hepA vaccine, but then this is a requirement through work.

 

[Ivor the Engineer]

Cost benefit, I can discuss. Ivor has a blindspot for the severity of the risk and only sees the frequency but at least he is using some logic.

I really want to know which world you live in where economic realities, such as finite resources being distributed fairly and efficiently in the face of infinite demand, does not impact what treatments are worth implementing for which members of society.

Earlier, I posted a link to a study that has indicated reducing the Men. C vaccination to 1 dose at 12-months and a catch-up campaign for under-18 year-olds, can save a huge sum of money (100's of millions of £) for a tiny increase in the number of cases of meningitis, compared to a 3-dose infant strategy.

It is you and EoE who appear to think that to just keep on spending more and more on vaccination will automatically be efficient use of health care expenditure. Well, I'm sorry to tell you, but you are wrong. All of the recent vaccination programs cost a lot more money that they save.

When I use the word 'efficient', I am talking about reducing suffering and death in a society by the greatest amount for the minimum expenditure. If all treatments were implemented this way, suffering would be reduced to a minimum given the expenditure people are prepared to pay for health care. This has to be balanced against emotionally-driven 'wants' of spending millions to, for example, save a single child's life, even though the money could relieve more suffering or extend more people's lives if spent on other treatments.

I really don't know where you are getting the idea I don't understand the severity of the risk for such things as chickenpox. I have looked at the numbers and studies in the UK and it does not make health-economic sense to vaccinate all infants. If a vaccination is introduced, it makes far more sense to delay it until adolescence, so only those individuals who have not had chickenpox are offered the vaccine.

EoE:

I read in another thread that you made a decision to get yourself a flu shot but not your kid(s), given your budget. It sounds like you made an implicit cost-effectiveness calculation and decided the impact of you being seriously ill was greater than your child(ren) getting sick.

BTW, I hope your child gets better soon

 

[Ivor the Engineer]

My family all had vaccine shots this year. We travel abroad (outside the UK) often enough to justify it.
I am vaccinated to my eyeballs because of my (medical) work - this includes Hep B, annual flu, smallpox.
If any of my kids really gets the travel bug, vaccinations will include whatever is appropriate, including Hep B. I will want my daughter to get HPV vaccine, and when a herpes vaccine is available I guess they will have that too.

Only about 5 people die in the UK each year from malaria. A standard course of malaria chemoprophylaxis for travellers costs about £40 (it is not "free" on the NHS).
With a "risk-benefit" ratio as low as this, I suppose some people here will not want to bother taking prophylaxis for their safari trip to Kenya.

Well that's great for a GP in the UK on £100k+ a year, but what about the family of four getting by on less than a third of that? How should the state decide whether or not to pay for their vaccinations?

I was supposed to get HepB when I was working at the Forensic Science Service, but since I was on a 1-year contract, never got round to it.

As for paying for malaria chemoprophylaxis for a safari trip to Kenya, I think £40 on top of the cost of the holiday (probably several thousand pounds) is insignificant.

This page gives advice for the risk in various regions, and Kenya is classed as very high. Each year about 2000 people in the UK get malaria from travel abroad.

Personally, given the number of insect bites I recieve in the UK all year round, I'd pay for malaria prophylaxis if going to a high risk area, just as I pay for travel insurance when I go skiing.

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=2364479&dopt=AbstractPlus

A longitudinal survey was conducted among travellers departing from Nairobi airport to determine the use of malaria prevention measures and assess the risk for malaria while travelling in Kenya. Among 5489 European and North American travellers, 68 different drug regimens were used for prophylaxis, and 48% of travellers used both regular chemoprophylaxis and more than 1 antimosquito measure during travel; 52% of 3469 travellers who used chemoprophylaxis did so without interruption during their travel and for 4 weeks after departure. Compliance was lowest among travellers who visited friends and relatives, who were young, or who stayed more than 3 weeks. Sixty-seven (1%) travellers experienced symptoms of malaria, but the diagnosis could be verified for only 16 of these. Long-stay travellers appeared to be at higher risk for malaria than short-stay travellers, and health information needs to be targeted especially to the former. Similar investigations are needed among international travellers to other malaria-endemic countries. With comparable data available, consistent and effective malaria prevention guidelines can be developed.

So even if it was a 1/10th of 1%, that's a pretty high risk for such a serious disease.

ETA: http://www.ncbi.nlm.nih.gov/sites/e...med.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

OBJECTIVES--To identify which British residents travelling abroad are at greatest risk of malaria infection, and to determine the efficacy of malaria chemoprophylaxis for preventing P falciparum infections in tropical Africa. DESIGN--Prospective cohort study (case-base linkage) with routine national surveillance systems. Denominators (base population) were obtained from monitoring a random sample of returning British travellers with the international passenger survey. Numerators (cases) were obtained from reports of malaria infections in British residents, through the Malaria Reference Laboratory network. SETTING--International passenger survey conducted at passport control of international airports in Britain. Malaria reports received nationally were collated centrally in London. SUBJECTS--2948 British residents (0.2%) returning to Britain in 1987 randomly selected and questioned and 1052 British residents with microscopically confirmed malaria infections in 1987, whose case reports were reviewed and on whom additional data were collected by postal survey. MAIN OUTCOME MEASURES--Annual incidence subdivided by categories of risk. Chemoprophylactic efficacy for east and west Africa by principal regimens and compliance. RESULTS--Annual rates of reported infection per 100,000 travellers to Oceania were 4100; to west and east Africa were 375 and 172 respectively; to Latin America, the Far East, and the Middle East were 12, 2, and 1 respectively. Immigrants visiting friends and relatives in Ghana and Nigeria were at greatest risk (1303 and 952 per 100,000 respectively) in west Africa. Business travellers to Kenya experienced the highest attack rates in east Africa (465 per 100,000). Age-sex specific attack rates varied by region. No prophylaxis was reported to have been used by 23% of British visitors to west Africa, 17% to east Africa, 46% to central or southern Africa, and 58% visiting south Asia. The efficacy of chloroquine plus proguanil against P falciparum infection was 73% and 54% in west and east Africa respectively. Lower values were obtained for chloroquine alone and proguanil alone. The efficacy of Maloprim (pyrimethamine-dapsone) was 61% in west Africa, but only 9% in east Africa. Visitors to west Africa who did not comply with their chemoprophylactic regimen were at a 2.5-fold higher risk of infection than fully compliant users. Non-compliant visitors to east Africa had similar rates of infection as non-drug users. CONCLUSIONS--In 1987 chloroquine plus proguanil was the preferred chemoprophylactic regimen for P falciparum infection in Africa; antimalarial drugs must be taken regularly to be effective.

 

[Beth]

Racial and Ethnic Disparities in Infant Mortality Rates --- 60 Largest U.S. Cities, 1995--1998

Infant Mortality and Low Birth Weight Among Black and White Infants --- United States, 1980--2000
See anything there which shows a "pretty clear connection" to multiple vaccines used?

And you guys claim you aren't CT nuts. If trying to make the IMR an indicator the US is using too many vaccines isn't as warped as a CTer's logic, I don't know what is.

(emphasis mine)

Go back and look at my graph. The 'pretty clear' connection I referenced in my graph was the inverse correlation of mortality for children under 5 with the vaccination rate. In other words, I was saying the graph supports your stance. Sorry I didn't make that explicit. Please stop the baseless accusations. Thank you.

 

[Rolfe]

Ivor, to my mind, had a point when he suggested that the cost of chickenpox vaccine might be better spent on medical aid to the third world. I then asked him which other healthcare items available in the UK he would like to see discontinued in order to increase medical aid to the third world. Didn't get an answer.

Now we're back to the chickenpox vaccination not being cost-effective in the context of UK healthcare per se. So I'm back to feeling that I'll go with the opinion of the professor of paediatric epidemiology who has studied the subject in detail, unless Ivor can point out exactly where he's wrong or mistaken. Irrelevent ranting about road accident or swimming pool fatalities just isn't relevant.

Ivor, tell me this. Just suppose the decision is taken, the deed is done. All children here are to have chickenpox vaccination recommended, in spite of your reservations. Now, will you have your child vaccinated? Remember, at this stage it won't cost you a penny. Whether or not you take up that vaccine will have no effect whatsoever on your household finances. Or, realistically, on the NHS budget as a whole.

What will you do?

Rolfe.

 

[Ivor the Engineer]

Ivor, to my mind, had a point when he suggested that the cost of chickenpox vaccine might be better spent on medical aid to the third world. I then asked him which other healthcare items available in the UK he would like to see discontinued in order to increase medical aid to the third world. Didn't get an answer.

Now we're back to the chickenpox vaccination not being cost-effective in the context of UK healthcare per se. So I'm back to feeling that I'll go with the opinion of the professor of paediatric epidemiology who has studied the subject in detail, unless Ivor can point out exactly where he's wrong or mistaken. Irrelevent ranting about road accident or swimming pool fatalities just isn't relevant.

How can I do that when you haven't provided me with enough information about what he thinks? Why should it be assumed he's free from bias?

Ivor, tell me this. Just suppose the decision is taken, the deed is done. All children here are to have chickenpox vaccination recommended, in spite of your reservations. Now, will you have your child vaccinated? Remember, at this stage it won't cost you a penny. Whether or not you take up that vaccine will have no effect whatsoever on your household finances. Or, realistically, on the NHS budget as a whole.

What will you do?

Rolfe.

I would probably wait to see if they get chickenpox before they are older and at increased risk of complications. Exactly what age, I don't know. Not having to worry about booster vaccinations every 10-20 years for the rest of their lives seems quite an advantage to me.

Here's some cost per QALY of various treatments:

Treatment £s Cost/QALY

Cholesterol testing and diet therapy 280
Advice from GP to stop smoking 350
Heart pacemaker implantation 1,420
Hip replacement 1,520
Coronary artery bypass graft 2,700
Kidney transplant 6,080
Breast cancer treatment 7,460
Heart transplant 10,110
Continuous ambulatory peritoneal dialysis 25,630
Neurosurgery for brain tumour 139,040

 

[Beth]

Correlations between child mortality rates & vaccinations

Here is a table of the correlations from 1990 to 2005 for child mortality rate (under 5) with 2 different vaccinations (measles and DPT) for kids from 12 to 23 months. The numbers in parentheses are negative, representing inverse correlations. What's interesting is that Sweden has positive correlations with both (higher vaccination rate correlates with a higher child mortality rate), the US and Germany have negative correlations with both (higher vaccination rates correlate with lower child mortality rate) and the U.K. has a positive correlation with measles and a negative correlation with DPT.

While this data doesn't indicate anything conclusion, I find it interesting. All of the negative correlations are stronger than any of the positive correlations.

Looking at all 4 countries combined, I get the following correlations for DPT and measles respectively:

1990-2005 -0.318 -0.415

While correlation does not imply causation, too many other things are also tied up with vaccination and mortality rates, it seems like fairly clear that an increaase in those two vaccines are generally associated with a decrease in child mortality.

 

[Deetee]

Well that's great for a GP in the UK on £100k+ a year, but what about the family of four getting by on less than a third of that? How should the state decide whether or not to pay for their vaccinations?

Only fulltime English GPs average over £100k.
And no - I'm not a GP.

The cost-benefit equation for vaccines would be determined by their basic purchase price - whether they are free on the NHS or payment per item such as Gardasil/HPV vax is immaterial to the calculation.

As for paying for malaria chemoprophylaxis for a safari trip to Kenya, I think £40 on top of the cost of the holiday (probably several thousand pounds) is insignificant.

Agreed. I was just pointing out that someone might ask why they have to pay what is a not insignificant amount of money to prevent a disease that kills only 5 people each year in the UK. You have decided the money is worth it. Epidemiologists, biomedical scientists, health economists and doctors have decided that most vaccines are also "worth it" and are willing to put NHS funds aside to pay for their provision.

All of the recent vaccination programs cost a lot more money that they save.

When I use the word 'efficient', I am talking about reducing suffering and death in a society by the greatest amount for the minimum expenditure. If all treatments were implemented this way, suffering would be reduced to a minimum given the expenditure people are prepared to pay for health care. This has to be balanced against emotionally-driven 'wants' of spending millions to, for example, save a single child's life, even though the money could relieve more suffering or extend more people's lives if spent on other treatments.

I understand your dilemma.
Virtually ALL medical interventions cost more money than they save. (The single most cost-effective intervention is I believe persuading people to stop smoking). Interventions such as treating heart attacks, asthma attacks, meningitis, cancer etc will all cost more money than they "save".

You talk about health care interventions which operate on QALYs - quality adjusted life year - Things such as heart bypass operations and transplants have a very high cost per QALY. Vaccination typically has a moderate cost per QALY. People have tried to calculate these for pneumococcal vaccine and [also previously referred to in this thread] for varicella vaccine)

You could run the IHS (Ivor's Health Service) by only providing medical care through interventions that are under a certain QALY score you have decided offers "value for money". If you did, you and your family would not be able to get many treatments or have complex procedures/operations. And, as altruistic as you wished to be, someone could always criticise you for offering the interventions you did allow by saying that the money would have been better spent giving more QALYs and reducing suffering and death more if only it were used in the Third World instead.

 

[Ivor the Engineer]

<snip>

You could run the IHS (Ivor's Health Service) by only providing medical care through interventions that are under a certain QALY score you have decided offers "value for money". If you did, you and your family would not be able to get many treatments or have complex procedures/operations. And, as altruistic as you wished to be, someone could always criticise you for offering the interventions you did allow by saying that the money would have been better spent giving more QALYs and reducing suffering and death more if only it were used in the Third World instead.

In the case of disease that only exist in humans, it would seem sensible to try to eradicate them. So let's send skeptigirl and the other members of the vaccination squad over to the third world and rid the world of measles before we think about chickenpox in the West. Once a disease has disappeared, no one has to be vaccinated against it.

BTW, on IHS the budget does not have a sharp cut-off for treatment Cost/QALY, but rather a graded allocation over various ranges. I.e. there are many Low Cost/QALY treatments available, fewer Medium Cost/QALY treatments and so on. This allows IHS to somewhat meet people's 'wants', as well as remaining reasonably efficient.