Archive

Archive for the ‘vaccination’ Category

Religion, Assimilation, Vaccination

February 9th, 2010 1 comment

According to this story, an outbreak of mumps has occurred in counties just north of New York City, mostly in Orthodox (or Hasidic) Jewish communities, where parents routinely seek religious exemptions to vaccination requirements for their children. In total, about 1,000 kids (mostly adolescents) have been afflicted.

When I was a kid, we all came down with mumps, and more: measles, chicken pox, and so-called “German measles” (rubella) were the most common. Mostly, these were cause for missing a week or so of school, but nothing more. Yet all of these diseases are properly seen as deadly threats to the public’s health. Measles, which is particularly likely to spike in a population where a significant number go unvaccinated, routinely killed many hundreds of kids each year in the U.S. alone, caused about double that number of permanent brain injuries, and cost the health insurance system dearly through the many thousands of hospitalizations. Mumps, in addition to the quasi-endearing chipmunk cheeks we all had, was most often associated with deafness as a complication.

The outbreak sits at the confluence of two infuriating obstacles to vaccination: bad science and over-deference to religion. Apparently, the outbreak in the U.S. was an unwanted import from the U.K., where a mumps outbreak had spread to some 4,000 people. Vaccination exemptions are frighteningly common there, mostly because of a thoroughly refuted study that purported to show a link between vaccinations and autism. Indeed, the prominent British medical journal that had published the study, the Lancet, last week retracted it after a British medical panel concluded that the lead author had been unethical and had conflicts of interest. And a flood of other studies since that one had already disproven its autism-vaccination link.

Once mumps made its way into the U.S., the congregation Orthodox and Hasidic Jews proved fertile ground for its spread. One locus was an area within Rockland County, New York, where a large, insular community of Hasidic Jews lives. I grew up in Rockland (in a nearby town), and know the community. On a Saturday, we’d drive past the synagogue-going residents — all on foot, the men in simple black garb with a defining hairstyle, the women in long dresses with head covering. Quite an insular community, and one in which, (credible) rumor had it, the families didn’t pay property taxes on their homes (each being considered a holy place). So there’s one exception from general laws that they enjoyed.

I didn’t know until recently of this other exemption for vaccinations, and I don’t support either carve-out. (In my view, no church should be exempt from paying property tax in the first place. There’s another whole post there, but I digress.) Respecting religion doesn’t require subjecting the public to needless risk. Quite the contrary: Religion is honored when we find and protect a proper, separate space for it. But personal or congregational religious expressions should end where the interest of the general public — a secular interest — is imperilled. Thus, it’s hard to justify a ban on the burka in public spaces (compare, say, driving, if evidence showed that the compromise to peripheral vision was significant), but equally hard to justify allowing the adherents of any religious group to forego vaccination. It’s easy to forget the public health success story of vaccinations. This recent story on those confronting new challenges from polio, many decades after they were first afflicted, should be reminder enough — but probably won’t be.

What’s the public health threat if everyone else is vaccinated? First, there’s the threat to the unvaccinated children themselves. The state has an interest in them, too, and at least one state supreme court has held that this interest makes unconstitutional any non-medical exemption. Beyond that, the vaccinations are themselves not completely effective. Thus, even the vaccinated kids can come down with the illness in question; and some of them will if a sufficient number in the population is not vaccinated. So it’s not “just” a question of getting to decide what to do about your own child’s health, an issue that the state has an interest in anyway.

When they first enacted religious exemptions to vaccination requirements decades ago, states did do under duress: Congress tied recognition of such exemptions to federal funding. It’s time to wake up and repeal these laws before we undo this great public health accomplishment.

Promise and Caution: Assessing the New HIV Vaccine

September 24th, 2009 1 comment

It’s all over the news this morning: The U.S. Army (partnered with the Thai Ministry of Public Health and the National Institute of Allergy and Infectious Diseases) has shown a modest, but statistically significant, protective effect from a vaccine against HIV.

Here are the details. The trial, which used a vaccine that is a combination of two others that had failed, involved some 16,000 Thai citizens, and was targeted at a strain of HIV that is common in that part of the world. The result was that those who received the actual vaccine were more than 30% less likely to be infected with HIV than those who’d received a placebo.

As this BBC report (click on 9/24 show) reminds us, there’s a small chance that the disparity is a statistical glitch. In the much likelier event that the result is real (and can be replicated), though, this constitutes a major breakthrough. Even quite recently, one could read only dismal prognoses for the development of a vaccine against HIV — most scientists believed it was far off, if not impossible. It’s fair to say that this latest trial was greeted with a great deal of skepticism, too.

What will this mean? What should we do, from a public health point of view, with a protective effect of about 30%, which is much lower than the 70-80% that researchers typically look for before licensing a vaccine? It depends. Right now, the mechanism by which the vaccine works isn’t understood: For one thing, it’s puzzling that those who became infected received no protective effect from the attempted immunization. Typically, where a vaccine confers incomplete protection, those who become infected have some response to the vaccine, even if it is too weak to prevent infection. So for now, it seems the best course is to work towards better understanding of this vaccine’s mode of operation, thereby to design a better candidate that will confer immunity on a much higher percentage of the population.

If that’s not possible — if this vaccine turns out to be a dead end, with scientists getting stuck at 30% protection — then it will be time to consider licensing it, thereby gaining a significant tool in the prevention arsenal. The vaccine, which requires more than one injection, will then best be seen as part of a comprehensive prevention strategy that continues to emphasize condom use, male circumcision,  education, and the social and economic empowerment of women.  Reducing the percentage of infection by 30% has enormous ripple effects, as those in the protected group are then incapable of passing infection along. Over time, the combination of strategies — with a modestly effective vaccine as a substantial component — can be expected to significantly lower the staggering global costs of HIV; costs that have been measured, for thirty years on, both financially and in terrible human suffering.

Categories: HIV/AIDS, public health, vaccination Tags:

The Broadest Rule Ever Told

March 11th, 2009 No comments

The War in Iraq, the erosion of our global political capital and standing, the response to Katrina, the economic collapse — with so many delicious delicacies of abject failure ripe for ingestion (and expulsion!), it’s little wonder that other Bush Administration disasters got lost in the shuffle. It’s kind of like being the fourth Baldwin brother.

As is generally known, and as is to an extent common to all lame duck presidencies, Bush et al. pushed through a number of “midnight regulations” designed to perpetuate their policy preferences. In this case, though, many of these last-minute changes had the effect of leaving a residue not unlike the smell of Limburger cheese.

Among the most pernicious is the “Provider Conscience Act,” which isn’t a legislative “act” at all, but a rule created by the Department of Health and Human Services (“HHS”). This rule, which went into effect on the last day of Bush’s historically inept tenure, creates an amazingly broad “safe harbor” for anyone who refuses, for reasons of “religious beliefs” or “moral convictions,” to perform any “health service” at all. (The rule applies to any entity that receives federal funds; effectively, almost all of them because of Medicare and Medicaid.)

This language could hardly be broader. HHS refused to define “health service,” or to specify what will count as valid “moral convictions.” As a practical matter, anyone who is remotely connected to any health-related procedure (because those who assist medical personnel are also covered by the exemption) can refuse to do anything that conflicts with whatever they believe. (Good luck winning a challenge to the sincerity of the “belief” after the fact.) They don’t need to refer the patient to another provider who might be willing to perform services that the patient is actually legally entitled to. Nor does the provider need to inform the patient of these “limitations” until the moment of refusal.

Before this blunderbuss rule was put into place, there were already several sources of federal legal protection for those providers who refused to provide abortion services. Over the years, parties offering, seeking, and declining to provide such services have all learned how to live with these restrictions. But this new “act” goes well beyond the context of abortion, potentially applying to birth control, as well. And not only birth control: In principle, there is no service, operation, or procedure that isn’t covered by this rule.

Does a doctor, or her assistant, oppose vaccination? Don’t vaccinate. (Will the parent take the child to another physician who will vaccinate? Perhaps not, and you can expect a public health peril to develop.) And the doctor can’t fire the person who refuses, because the law protects the “conscientious objector.”

Refusing to provide blood transfusions? Not willing to fill prescriptions for birth control drugs needed to ensure a woman’s health? These and countless other decisions are protected under this rule. HHS was impervious to arguments that this open-ended rule could lead to health care providers refusing to perform any task for any reason at all, but it’s less understandable that a law professor would agree. Yet in an installment of Radio Times (search for 12/16/08 show), St. Thomas University law professor Teresa Collett brushed aside these concerns, telling me that the law, while broad, wouldn’t lead to the kinds of problems I’ve just identified. There is no basis for her confidence.

There’s likely good news. The Obama Administration opposes the rule and has already begun the process that could repeal it.  And the Attorney General of Connecticut, one Richard Blumenthal, has sued (along with others) to enjoin the rule. But for now, the rule threatens public and private health and places providers’ whims over patient safety and autonomy.

Is it Trash Day yet?

{an acknowledgment to Dan Whitney, a student whose solid paper relating to this topic saved me research time and effort}

Blogging from an iPhone?

March 3rd, 2009 No comments

Let’s see if this method of blogging is even workable; it might inspire concission but I would not bet too much on that happening. I am doing this out of necessity (to the extent I am obsessed enough to need to blog every day), but it will be interesting to see how it turns out.

Seeing “The Reader” at the same time I have been reading Edward Jenner’s “Vaccination Against Smallpox” naturally inspired reflection on whether humans can ever reach moral consensus, let alone absolutism. As everyone who has seen “The Reader” knows, Kate Winslet’s character performed unspeakable acts of what today, at least in the proper community of nations, would be universally condemned. Yet the very banality of her evil (to crib Hannah Arendt’s phrase), driven in part by her humiliation because of illiteracy, somehow makes her actions more chilling than those of policy-makers from Hitler on down. Without SS workers who regarded their service as nothing more or less than a 9 to 5 job, none of the terrible “successes” of genocide — by Nazis or anyone else — would be possible.

But moral relativism walks more stealthily in most cases. Jenner describes dozens of cases illustrating his thesis that cowpox infection protects against the far more serious and often deadly smallpox menace. Jenner was a brilliant observational scientist who devised the first-ever vaccination against any disease, and he is rightly revered for doing so. Yet reading his work today provides a stark reminder of the differences between the ethics of human experiments in 1798 and now.

To test his theory that prior exposure to cowpox was protective against smallpox, Jenner innoculated many people with smallpox. He was doubtless delighted when none of the subjects developed smallpox! But far more chilling was his decision — presented matter-of-factly by the author — to innoculate a boy who had not had cowpox with smallpox. Predictably, this child developed full-blown smallpox, with what ultimate health consequences, Jenner doesn’t bother to disclose.

What explains these cases? For the record, I don’t consider myself a relativist on the most basic issues, whether it is Nazism, the rape of Congolese women, or the use of non-consenting human subjects. Yet a powerful group mind set is in evidence. It shows up everywhere, even in voting preferences: live around Democrats, vote democratic. Live around Republicans — I can’t go on….

Combine that group impulse with the demonstrated role of emotions in casting one’s decisions (explaining why an illiterate, driven by shame, made so many choices that were immoral and even against her own interests), and you have a good starting point for explaining the relativist urge. But is there no way past it? Or at least around it?

Progress Forgotten

February 18th, 2009 1 comment

Here’s a description of a deadly disorder that once afflicted children:

“At first children undergo subtle personality changes, their handwriting deteriorates, and they seem to forget things. Later, when the horror of the disease fully emerges, children are progressively less able to walk, stand, or talk; then they become combative, have seizures, lapse into a coma, and die.”

This quotation appears in Dr. Paul A. Offit’s book, “Vaccinated,” (pp. 44-45) where Dr. Offit, chief of the division of infectious diseases at the Children’s Hospital of Philadelphia, is describing a uniformly fatal disease that afflicted children who had contracted measles. This disease, subacute sclerosing panencephalitis, usually began years after the acute infectious stage of measles — but the acute phase itself could be deadly. Before vaccination became widespread, about eight million kids died every year from measles, while many more suffered deafness, blindness, brain damage, and damage to other vital organs.

And that’s just measles: Other diseases of childhood, including mumps, rubella, polio and pertussis accounted for many more deaths, permanent disabilities, and birth defects. I’m not even discussing smallpox, the early vaccination against which has saved countless millions of lives by this point.

This little historical reminder was brought to you by your Local Public Health Authority, in cooperation with the Centers for Disease Control and Prevention (“CDC” ) and the World Health Organization (“WHO”). It  turns out that these facts can’t be repeated enough.

Last week, special masters in three cases brought by parents of autistic kids rejected claims that the children’s autism was brought about by the measles, mumps, rubella (“MMR”) vaccine or by a preservative, thimerosal, in the vaccine. In so finding, these special  masters were echoing a chorus of scientific research and population-based studies finding no link between vaccines and autism. One of the special masters, while expressing sympathy towards the child, went so far as to say that the family had been “misled by physicians who are guilty, in my view, of gross medical misjudgment.”

Don’t expect the effort to tie autism to vaccines to stop any time soon, though. A spokesperson for an organization called Generation Rescue called the decisions “an incomprehensible injustice.” The organization’s website, turning a dramatic public health success on its head, claims (without evidence) that the increase in autism and related disorders is related to a “tripling” of the number of vaccines given children in the last fifteen years.

Of course, the safety of new and existing vaccines needs constant monitoring. But this kind of irresponsible failure to accept widespread scientific consensus makes the work of physicians and public health more difficult by contributing to a culture in which increasing numbers of parents seek exemptions from vaccination requirements.

Speaking of the culture of scientific fantasy: On the premier episode of the goofy drama-dy “Eli Stone” last year, the vaccine-autism link was given pop credence when attorney Stone convinced a jury — to the tune of over $5 million — that his client’s condition was brought about by the mercury-based preservative in a vaccine. ABC responsibly posted discussion effectively refuting the link, but the show’s imagery and dramatic elements are likely to overwhelm the more reasoned discourse.

There are rare cases in which a child’s medical condition might counterindicate administering a particular vaccine for a period of time. Those aside, we should immediately do away with all exemptions — religious, philosophical and otherwise — to the immunization of our children. If we don’t, we run the ever-increasing risk of compromising the “herd immunity” that protects us all. If these diseases resurge, let’s see whether people will continue to object to vaccinations against them.

Only a safely vaccinated population has the luxury of manufactured hysteria.

Categories: autism, public health, vaccination Tags: , , , , , , , , , , , , , , , , , ,