America’s worst outbreak of measles in a quarter-century — racing toward 1,000 confirmed cases nationwide and with no signs of slowing— has brought to the fore the counter-factual arguments over vaccinations.
The controversies would be easier to resolve if grownups relied on medical science and centuries of experience. The facts lead to one overwhelmingly confident message: Get those shots for the youngsters, your teens, seniors, and yourself.
If you’re confused or want expert guidance before seeking counsel and the inoculations from your doctor, reliable information abounds.
As with any medical treatment, vaccinations carry risks. But these are outweighed by the benefits. So why are a vocal few, with extreme views, ready to strip all of us of the value of a crucial means of preventing diseases?
It’s key for all of us to stay atop our shots and the disputes about vaccines. These offer troubling insights into the challenges of living in a democracy when beliefs overpower facts and evidence and individuals assert the primacy of their privileges over the well-being of the many.*
Record-setting measles outbreaks show risks of skipping key shots
Your doctor or your kids’ pediatrician can be an invaluable resource for what you need to know about vaccine-preventable illness and the shots or boosters you and your loved ones may need. The federal Centers for Disease Control and Prevention (CDC) also has prepared helpful graphics about medically recommended inoculations, based on patients’ age. They’re shown throughout this newsletter and accessible online (click here).
If you wonder whether you should join the vaccine-hesitant, it’s worth reviewing your risks if you do so.
Long experience and rigorous research (see some of it by clicking here) has demonstrated how vaccines slashed the scourges of once-common infections and have done so with a strong safety record. The list of diseases is long: measles, rubella (so-called 3-day or German measles), chicken pox, diphtheria, mumps, tetanus, whooping cough, polio, meningitis, human papilloma virus, hepatitis (A&B), shingles, pneumococcus (pneumonia), and the flu.
These highly communicable diseases ravaged generations before us. But public health campaigns for vaccinations have succeeded so well that we have all but eradicated the threat of smallpox and had until recently accomplished much the same for measles. And few of us fret about, much less remember, the dread of getting polio and needing treatment in an iron lung.
Make no mistake, though: Vaccine-preventable illnesses still kill. Just consider that in the 2017-18 season, federal officials counted 186 pediatric deaths due to the flu — 80% of the youngsters who died had not received a flu shot. In 2017, 13 infants and children died due to whooping cough (pertussis). The likelihood of deaths rises, of course, when there are more cases of infections.
When vaccine-preventable diseases strike, the harms can get out of hand fast, forcing hospitalizations for dangerous fevers and dehydration, and leaving the infected susceptible to other illnesses. Hospital care comes with its own considerable risks, not the least of which is bank-busting cost: An un-vaccinated Oregon boy whose head gash turned into a preventable case of tetanus spent weeks in agonizing intensive care, eventually recovering but racking up more than $800,000 in hospital bills for his anti-vaccination parents.
Vaccinate Your Family, a nonprofit advocacy group launched by former First Lady Rosalyn Carter and Betty Bumpers, the onetime First Lady of Arkansas, reports that “vaccines given to children born between 1994-2016 will prevent an estimated 381 million illnesses, 24.5 million hospitalizations, 855,000 deaths, and $1.65 trillion in total societal costs.”
Even if young people suffer a more routine vaccine-preventable illness, they can be ordered to stay away from peers and may be sick at home for longer than many parents can handle: The incubation period of chicken pox can run 10-21 days. It can be 12-25 days for mumps and 14-21 days for rubella.
That would be a lot of time to be off the job for many working moms and dads. It would put youngsters behind in their studies, could make them an anxious, restless, and cranky handful to take care of for spans longer than many academic vacations. It may be worse for older kids off at college. Their course work can be intense, and outbreaks of meningitis and mumps, if they are un-vaccinated and get sick, can hurt their academics and derail their matriculation schedules.
Infectious diseases are serious business. But some parents take an extreme view, without evidence, that the shots are riskier, so much so that they hold infection parties. At these events their youngsters avoid vaccinations by being in contact with infected youngsters and getting sick themselves with illnesses like measles and chicken pox. Kentucky’s governor says he took this extreme step with his nine kids. Really?
Diseases come with consequences. And they’re very often shared. Widely.
Still wobbly about the shots? (As an aside, the British term is a bit less scary and more accurate than “shots;” they call them “jabs.”)
As parents know, vaccinations are an inarguable part of enrolling kids in school whether they are starting out kindergartners or college freshmen off to new challenges. States make these regulations, and battles have brewed across the country to toughen them by eliminating exemptions.
With year-round school calendars, making appointments and getting in to see a doctor for recommended vaccinations is no longer just an August health ritual. Don’t tarry, because doctors’ offices get jammed as summer rolls on and many families get back from vacation and focus on the next school year. You may find you can get shots for you and your loved ones at free-standing retail clinics that have flourished in drug stores. Your public health department may have recommendations about its facilities that offer inoculations.
Be sure you keep a record of shots that you and your loved ones receive. This once was a common and familiar paper document. It can be important with the rise of electronic record keeping and systems that may not talk to each other that you know this information and keep it handy for reference. With measles and other infections, greater protection may be achieved with booster shots. Or patients may find that they didn’t get full immunization regimens for a variety of reasons, including changing medical recommendations or for the simple reason that they moved a lot when young. You also may not need certain shots because you have had an infection already and now have immunity.
Parents also may find that summer camps and other programs will be more insistent than ever about ensuring that participants have been vaccinated. If authorities deem you or yours a health risk because you’re not immunized and may be carrying a disease, they’re talking tough these days and may even put you on nationwide lists that ban you from airline travel. Here’s hoping that you’ve already folded into any major summer travel plans the time to see a health care provider for more specialized shots, especially if you and loved ones are headed overseas.
Due to the U.S. measles outbreaks, experts are underscoring the need for this vaccination for travelers. That’s because domestic cases often have been traced to people exposed overseas or to those who visited this country from areas with measles outbreaks.
The CDC has modest (level 1) warnings about measles in Israel, Japan, Brazil, the Philippines, and Ukraine. The European Union in mid-May reported high numbers of measles cases in Romania, France, Poland, and Lithuania. Italy has struggled for a while with measles.
The World Health Organization (WHO) surprised many by declaring earlier this year that growing global resistance to vaccines ranks among the group’s top 10 threats to health worldwide:
“Vaccination is one of the most cost-effective ways of avoiding disease – it currently prevents 2 million to 3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccinations improved. Measles, for example, has seen a 30% increase in cases globally. The reasons for this rise are complex, and not all of these cases are due to vaccine hesitancy. However, some countries that were close to eliminating the disease have seen a resurgence.”
A fundamental fear held by medical experts worldwide is the erosion or possible loss of community or “herd” immunity. As the federal Health and Human Services department explains this crucial concept:
“[W]hen enough people are vaccinated against a certain disease, the germs can’t travel as easily from person to person — and the entire community is less likely to get the disease. That means even people who can’t get vaccinated will have some protection from getting sick. And if a person does get sick, there’s less chance of an outbreak because it’s harder for the disease to spread. Eventually, the disease becomes rare — and sometimes, it’s wiped out altogether. Community immunity protects everyone. But it’s especially important because some people can’t get vaccinated for certain diseases — such as people with some serious allergies and those with weakened or failing immune systems (like people who have cancer, HIV/AIDS, type 1 diabetes, or other health conditions). Community immunity is also important for the very small group of people who don’t have a strong immune response from vaccines.”
The New York Times has a further explanation of herd immunity and its importance, reporting:
“The threshold for herd immunity varies by disease — for a highly contagious disease, a very high percentage of people need to be vaccinated to meet that threshold. Because measles is so contagious, between 93 percent and 95 percent of people in a community need to be vaccinated to achieve herd immunity.”
So, in a time when technology and transportation advances have shrunk the globe for so many of us, the reality is that we’re relying still on everyone around us to collectively stay and get healthier. We need to do our part because we are confronting infections that may be new, may be familiar but changed, can spread quickly, and may not be treated as easily. This may be due, for example, to overuse that has caused legendary antibiotics and antifungals to decline in effectiveness as harmful bugs develop powerful resistance to them.
We’ve also endured a decade of angry debates over U.S. health care, specifically government assistance for insurance for poorer and middle-class Americans through Medicaid, Medicare and now Obamacare. Political partisans have insisted that individuals must bear the crushing costs of medical services, without shared or collective help. They deny the widely held and good idea that health care is a right, not a privilege. Though we’re all a catastrophic injury or illness away from ruin, well, if it happens, tough luck and take care of it on your own, by yourself, Republicans in Congress have told the American people. Really?
New ways to reach consensus and safeguard our collective health?
The fractiousness now surrounding vaccinations — once eagerly joined in and widely praised — cannot be overlooked in a democracy like the United States.
It is unhelpful to demonize the vaccine-hesitant or those who reject inoculations. Some may be ignorant or misinformed. But the many ways in which they come to their strong beliefs should not be dismissed. We seemingly can’t change their minds with facts alone, especially by ticking these off loudly at them.
The anti-vaccination movement, of course, traces in recent times to an infamous medical fraud: The publication in a respected medical journal of a soon-retracted article linking vaccines to autism. In other times, the author of such a debacle would have gone off to professional exile and infamy. Instead, Andrew Wakefield has become a cult figure, appearing, for example, at President Trump’s inaugural festivities.
Opposition to vaccinations has infected American politics, spreading into conservative and mainstream Republican circles, among the don’t-tread-on-us Libertarian-leaners of the Pacific Northwest, through purportedly progressive West Coast enclaves in Marin County in the Bay Area and Los Angeles’ Westside, and even finding an ally in a scion of the Kennedy family. The current measles spike may be biggest in the insular Orthodox Jewish communities in New York, where religious beliefs have complicated efforts to tamp down a disease that health officials thought might be on a permanent wane. (Religious leaders, by the way, told the New York Times that their faithful should get shots.)
Ed Day, the executive of Rockland County, N.Y., hard hit by a measles outbreak, sees big problems in those who oppose vaccination, telling the Washington Post, “This is a national movement of people who are nothing but charlatans, conspiracy theorists and people … spreading misinformation. The type of propaganda they spread is a danger to the health and safety of children within our community and around the world.”
–respected magazine Foreign Policy printed an Op-Ed by a scholar who argued that the anti-vaccination movement has online support from hostile U.S. adversaries, notably an aggressive Russia that hopes by trolling and use of disinformation-spreading bots it can amplify domestic disagreements to cripple America’s world leadership. This point of view was supported by published social media research by a George Washington University researcher.
The anti-vaccination crowd has exploited the new information channels of social media in ways never seen — and to the shock of the medical establishment. Doctors have found themselves under siege by anti-vaxxers targeting them with cyber hate and harassment campaigns. This, in turn, combined with spikes in preventable infections like measles, has caused a backlash against anti-vaxxers. Lawmakers on Capitol Hill have ripped social media companies and demanded they act, within appropriate free-speech bounds, to quash false information about vaccines. Instagram and YouTube both have taken such steps, and Facebook, as always, is dragging its feet but promises to act.
How best to respond to the emotion and the dearth of evidence from vaccination foes or those hesitant about inoculations? It’s a vital concern, not just in this controversy but in many others bedeviling American public life.
Experts say that it would be helpful for medical leaders to communicate better with patients, politicians, and the public. But education campaigns alone may not produce optimal outcomes.Neither will confronting and “duking it out” with media-savvy vaccination foes. Instead, conversations and comments from respected individuals, especially in small and closed communities, may help to shift opposition thinking. While doctors, insurers, and employers may need to be open to discussions about inoculations when patients initiate these, they also may want to use what economists call “nudges”: phoning, emailing, and texting patients asking when they want to schedule vaccination appointments, and telling them in person in pointed statements that they should get certain shots by fixed dates. Pediatricians may be well-placed to persuade parents about vaccination benefits, particularly if they don’t let their own biases get in their way, such as has occurred with the HPV inoculations and possible discussions with patients about sex. It’s clear that long, sustained effort will be required, especially at the individual level.
But tapping into alternative techniques while maintaining robust public health campaigns and quashing outbreaks when they occur can cost a lot of money — taxpayer money, of course. As Money magazine reported:
“How much do these measles outbreaks cost the United States? It’s impossible to pinpoint an exact amount. But the costs are often substantial, not only for tests and treatments of patients with measles, but also due to the need for additional staffing at hospitals and health departments, plus quarantining in some cases. Minnesota officials said that the measles outbreak of 2017 cost the state at least $1 million, while Washington state said that it spent more than $1 million dealing with measles just in the first two months of 2019. The costs are much higher for measles outbreaks on a national scale: Researchers say that the 2011 outbreak, when there were 16 separate outbreaks and 107 confirmed cases of measles, cost state and local health institutions somewhere between $2.7 million to $5.3 million. The circumstances behind each measles diagnosis are different, so it is also difficult to come up with a precise cost for each case of measles. But the CDC estimated that two individual, unrelated measles cases in Denver a couple years ago wound up costing a total of more than $68,000. Dr. Nathaniel Smith, the director of the Arkansas Department of Health, said … that a single case of measles probably now costs health services somewhere in the neighborhood of $50,000 … it would seem like the measles outbreak of 2019 will easily cost the U.S. tens of millions of dollars.”
That might not seem like much in the grand scheme of things. But these days politicians have been eager to slash budgets for public health programs, where every penny counts. (Savvy voters, by the way, might do all they can to encourage their elected officials as to how unwise it would be to reduce public health funding.)
What’s the choice? The CDC has tried to offer a brief answer:
“We know that a disease that is apparently under control can suddenly return, because we have seen it happen, in countries like Japan, Australia, and Sweden. Here is an example from Japan. In 1974, about 80% of Japanese children were getting pertussis (whooping cough) vaccine. That year there were only 393 cases of whooping cough in the entire country, and not a single pertussis-related death. Then immunization rates began to drop, until only about 10% of children were being vaccinated. In 1979, more than 13,000 people got whooping cough and 41 died. When routine vaccination was resumed, the disease numbers dropped again. The chances of your child getting a case of measles or chicken pox or whooping cough might be quite low today. But vaccinations are not just for protecting ourselves and [they] are not just for today. They also protect the people around us (some of whom may be unable to get certain vaccines, or might have failed to respond to a vaccine, or might be susceptible for other reasons). And they also protect our children’s children and their children by keeping diseases that we have almost defeated from making a comeback. What would happen if we stopped vaccinations? We could soon find ourselves battling epidemics of diseases we thought we had conquered decades ago.”
That’s a sobering thought. Here’s hoping, however, that the battles over vaccination prove to be productive, offering us lessons in: toning down our disagreements; finding common ground; affirming the value of science, evidence, facts, and research; how to better use social media to benefit rather than harm our health; and understanding the value, too, of personal persuaders and small nudges that can have big results. Let’s also not be naive and use research and all the resources available both to preserve free speech but to deal with extreme, nefarious parties who spread damaging conspiracy theories and divisive disinformation.
In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to obtain health care. This has become a more daunting ordeal than ever due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which prove to be dangerous drugs.
Patients have the fundamental right to informed consent, meaning they are told clearly and fully by their medical caregivers all the important facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom. If, as apparently has happened with vaccinations, there is misinformation or disinformation to be dealt with, the medical profession must do all it can to take the time to detail the benefits and, yes, risks of shots.
They also should underscore that experience shows that staying healthy and away from doctors and hospitals is a great way to avoid the peril of preventable medical errors, which experts estimate claim the lives of roughly 685 Americans per day. That’s more people than die of respiratory disease, accidents, stroke and Alzheimer’s disease. Get those shots for yourself and your loved ones and may 2019 and beyond see you and yours in peak health!
Vaccines can vary in their effectiveness
Centuries of concrete experience have demonstrated that vaccines work to society’s overall benefit. It can be tougher to explain to general audiences that individuals may experience wide differences in a vaccine’s effectiveness.
This is most clearly seen in the common utterances about annual influenza vaccines, as in: I got the flu shot and it gave me the flu (factually inaccurate) and I got the flu shot and it didn’t do any good because I still got the flu (possible).
The human immune system is so miraculous and complex that the Obama Administration announced a “moon shot” initiative just to try to advance knowledge about how it works with cancer. Immunizations address a range of diseases, and people react in varied ways to each of the shots, differentiating how well they work.
Research to determine this formally can involve clinical studies and mathematical analysis, as well as expert observation. Online searches for individual vaccines can quickly turn up studies published in medical journals about their effectiveness.
It also is true that certain vaccines just don’t work for some people, while others cannot get certain shots due to allergies or because their immune systems may be compromised by diseases like HIV-AIDS or cancer.
The workings of flu vaccines, which receive an annual torrent of deserved media coverage, can be tough for public health officials to explain. They take time to prepare for the scale at which they must be delivered, with tens of millions of doses. They need to help patients develop resistance to specific and multiple strains of a virus that mutates fast.
In prepping the annual flu shot, medical experts must anticipate which strains might be most prevalent in a given year based on an array of data, including outbreak information from around the globe. If their choices aren’t proven out, the flu shot in a given year may be less effective, though remember that vaccinations can be helpful for boosting overall community or herd immunity.
If an immunization is less effective, does it make sense to just skip it? No. With the flu, for example, a vaccine that’s less effective against one strain may allow it to rage early, with the shot showing far better results later as a different strain takes hold. Kids and seniors suffer a terrible toll with flu and its potential complications, so it may be a no-brainer for them to seek the potential protection of a shot.
There’s also this practical consideration for us all: How much do you want to gamble with your health? Las Vegas may flourish as an example of how poorly too many of us judge risks and rewards. If the costs and other burdens of vaccination are relatively low and the rewards are high — nobody wants to get sick, or worse — what’s the question?
Don’t forget this, too: Just a century ago, when flu shots were uncommon, an H1N1 pandemic erupted, infecting an estimated 500 million people or what then was a third of the world population. The disease killed 50 million worldwide, including 675,000 Americans. That’s a dire scenario always to be avoided.
Shots aren’t risk-free, and Uncle Sam has special ways to compensate for their rare harms
Vaccinations, like any medical services, carry risks. They’re small but real. Uncle Sam is clear in spelling these out, and the list of various immunizations’ side effects may be accessed by clicking here. The federal government also has been open and public — contrary to conspiracy theorists’ claims — that vaccines can cause harms.
Because immunizations provide such a significant public benefit, lawmakers and the federal government in 1986 set up a special method to protect the supply of vaccines and to deal with patients’ claims of vaccine-related injury, as the Atlantic and Time magazines have reported. The Vaccine Claims/Office of Special Masters, aka the “vaccine court,” is part of the U.S. Court of Federal Claims.
In brief, under the National Vaccine Injury Compensation Program, petitioners (as they’re called, not plaintiffs) file a complaint with the court, which asks the federal Health and Human Services (HHS) department to revidw the matter and offer its medical recommendation. The case then goes to the U.S. Justice Department, which offers its legal analysis and represents the government in the court. The court appoints special masters to hear a few thousand cases annually.
Disputes are handled in a no-fault manner. That is, the patient does not have to prove that there was something flawed in the vaccine. They only have to produce reliable evidence that their claimed injury came from the vaccine. The government also makes clear that even if petitioners don’t prevail in their claims, they still may be awarded attorney fees and costs.
Vaccination foes have tried to claim the court’s work is secretive, even as they point to its generous decisions as evidence that shots are too risky. Both notions are unfounded.
Time magazine has pointed out in a news article how widely available the government has made public information about the vaccination court, and it summarized the decisions in what it said was a clear refutation about shots’ harms:
“Even without blame being established, the billions [of dollars] the government has handed over in payouts since the [vaccine program] was created does seem to suggest that a whole lot of people are being harmed. But that is not the case. From 2006 to 2014, approximately 2.5 billion doses of vaccines were administered in the U.S. In that time, a total of just 2,976 claims were adjudicated by the special masters and only 1,876 of those received compensation. Divide that number by the vaccine dose total and you get less than a one in a million risk of harm. Going all the way back to 1988—before the flu vaccine became part of the recommended schedule of vaccines—a total of 16,038 claims have been adjudicated and 4,150 have been compensated, bringing the total payouts up to the $3.18 billion figure.”
Time and Atlantic both emphasize that the vaccine court’s payments need to be considered with caution: Many petitioners are children, and they individually may receive higher awards (which add up) because they may need long care; and the goal of the cases isn’t to dispute and reject claims but rather to support the harmed.
Uncle Sam’s involvement in dealing with vaccine harms also has ties to public health officials’ worry about ensuring inoculation supplies. Big Pharma, always seeking maximum profits, has low interest in stocking, supplying, and developing vaccines, especially if they have legal risk. Vaccine availability is a persistent concern, especially in worrisome times of high need. The federal Centers for Disease Control and Prevention tracks shortages and says these are few as of this writing. Hepatitis outbreaks have strained supplies, and Shingrix, a new and much praised a vaccine that protects older adults from shingles, may be difficult to obtain. Its maker has boosted production and supplies but patients may need to hunt around to get it or to get wait-listed for the two-shot imummunization.
Recent Health Care Blog Posts
Here are some recent posts on our patient safety blog that might interest you:
- Although the fatalities have declined, preventable hospital deaths kill more than 160,000 Americans annually — four times as many lives as were lost to vehicle wrecks in 2017, more than twice the deaths attributable to opioids and drug overdoses that year, and more than the toll of stroke or Alzheimer’s disease.The disturbing new report on hospital deaths comes from Johns Hopkins Medicine’s Armstrong Institute for Patient Safety and Quality and the Leapfrog Group, a national nonprofit founded by large employers and others concerned and focused on safety and quality in health care. The organizations’ data should be even more concerning for residents in and around the nation’s capital because researchers highlighted the heightened risks to patients of poor performing hospitals.
- Just as the nation grapples with the worst measles outbreak in a quarter century, the University of Maryland and public health officials are drawing fire for the way they handled the strange confluence of mold infections in dorms and the spread of an contagious virus among students on the College Park campus. The university and its advisers tried to keep a lid on public information about the dual problems, leading students and parents to assail the school and to blame its sluggish response and silence for the death of an immune-compromised coed.
- Hundreds of mothers die of preventable pregnancy-related complications up to a year after delivering their babies, with black and native women experiencing notably high maternal morality risks.The needless deaths of around 700 women nationwide each year due to cardiovascular conditions, infections, hemorrhages and other complications related to their pregnancies underscores the importance of improving maternal care, especially in increasing its access and quality, the federal Centers for Disease Control reported in a new study.
- Members of Congress have taken steps aimed at allowing service members to pursue actions in the civil justice system when they suffer harms while seeking medical services, a fundamental civil right now denied to military personnel. Members of the U.S. House Armed Services Committee heard powerful testimony from a Green Beret, an airman, and a judge advocate general about the need for a bill introduced by Rep. Jackie Speier (D.-Calif.) — a measure that has won bipartisan backing — to correct problems caused by a 69-year-old U.S. Supreme Court ruling in a case involving the Federal Tort Claims Act. That act governs who can bring a claim for negligence at a military or other government health care facility.
- As the nation rapidly grays and income disparities widen by the day, a sizable number of Americans — a group that built the nation to greatness and has been its economic bedrock — is headed to yet another ugly indignity: More than half of middle-income seniors won’t be able to afford their medical expenses and the cost of assisted housing they will need at age 75 and older. New research published in the journal “Health Affairs” has projected what already soaring medical and housing costs will mean to those whose incomes fall between $25,001 to $74,298 per year and are ages 75 to 84. These middle-income elders will increase in number from 7.9 million now to 14.4 million by 2029 and soon will be 43% or the biggest share of American seniors. But the picture for them and their finances, housing, and medical expenses may be glum. Projections show they will lack the money, even if experts calculate in their home equity, to afford assisted living they may need in their late years.
Patrick Malone & Associates