Where did we go wrong? Framing vaccination

I’ve had a bit of writer’s block lately, but I’ve learned to take my own advice and just wait it out. And so I did. Then, today, I read Orac’s piece on framing the vaccine problem. It set my mind a-whirring, so I’ve put the coffee on, and I’m setting fingers to keyboard.

I don’t care about the whole “framing science” thing. The systematic evaluation of science communication is too far outside my field. I am stuck being a “empiric framer.”

(Jargon alert! Outside of the blogosphere, my communications are basically one-on-one, doctor and patient. My framing is the equivalent of a RCT n=1 trial—I get a chance to intervene with a single subject and evaluate the response, but I don’t get the chance to study larger sample sizes and do statistical analyses of my work. End jargon)

The vaccine problem is currently an n=1 problem. Individual medical professionals work hard every day to educate individual patients. Decades ago, we didn’t need to convince anyone to get vaccinated—the need was so blindingly obvious that people lined up for their shots and prayed there would be enough to go around. Everyone saw polio, saw measles, saw people becoming disabled or dying from infectious diseases. Everyone watched as our public health improved with the wide-spread administration of vaccines. And now we are the victims of our own success—people don’t fear vaccine-preventable diseases because they no longer know them.

There is something here we in medicine are missing. Clean water and good sewerage are a no-brainer, and no one agitates to “free our water” (although they do with milk—go figure), but people do agitate to “green our vaccines“, whatever-the-hell that means.

So, after our successes at vaccination, we’ve gone soft. We no longer have widespread campaigns to encourage vaccination. And I’m not sure how a more cynical, media-savvy society would react to the old-fashioned approach anyway.

Well, it’s time to get off our asses. I just googled “vaccine education”. The first hit is the Vaccine Education Center, a great resource. A unique resource. And that’s the problem. It shouldn’t be “unique”—there should be “vaccine education centers” everywhere. Most of the other hits on google are for anti-vaccine propaganda sites. We’ve failed.

Time to stop sulking. There is a place for snarky invective. My writing, Orac’s, and others’ has great value (IMHO). I can only judge by commenters, but it seems to attract mostly those who strongly agree, and those who strongly disagree. That’s good, but not good enough. We need to communicate to everyone, and soon. Vaccine-preventable diseases are making a comeback, and I have enough work already. I don’t need more full hospital beds.

A little while ago, I started a Facebook group to explore the idea of communicating about vaccination. I didn’t really know what I wanted to do with it but I had a few ideas. Now I have more. The antivaccination crowd has a very effective grassroots movement to suck us back into the dark ages. They have an advantage—they are motivated by zeal, whereas most of us who believe in modern medicine are, shall we say, more level-headed and not prone to activism. It’s time to change that.

I propose that folks interested in brainstorming an effective grassroots way to encourage vaccination join the group and discuss amongst themselves strategies. This could be an epic phail, but it just might end up with some benefit. I don’t really care if the facebook group lives or dies, but if it gets people talking and working outside the insular blogosphere (and outside the insular facebook community), that’s good enough for me. I’m not looking for rabid antivax cultists or those on my side who are unable to set aside their snarkiness. I’m looking for people genuinely interested in communicating about vaccination with their friends, neighbors, coworkers, etc. I won’t vigorously moderate the group, but if people are being unproductive idiots, I may give them a gentle shove.

Roll up your sleeves, it’s time to get to work.

Comments

  1. #1 D. C. Sessions
    July 19, 2008

    A little while ago, I started a Facebook group to explore the idea of communicating about vaccination.

    Not a perfect choice, though, since FaceBook tracks your Web activity.

  2. #2 PalMD
    July 19, 2008

    Im all about privacy concerns, but that’s not exactly what the article you linked says. It says that they track purchases and target ads—still something I don’t like, but very different from the black helicopters haz ur pr0n.

  3. #3 Chris Granade
    July 19, 2008

    D. C. Sessions: That applies only for sites that opt-in to Beacon, so I imagine there’d be something one could do with the permissions on those sites that would block Beacon traffic. A bit of experimenting with WireShark may reveal an answer.

    Note that what I am not saying is that because only Beacon-enabled sites track you, it’s a-ok. I’m saying that because of that, it’s easier to recover privacy.

  4. #4 katie
    July 19, 2008

    It’s tricky tho. The anti-vax movement has set up this system so that as soon as people organize to promote vaccinations, it becomes a “government conspiracy”.

    Look at what happened with Gardasil. People organized to promote it, and now the anti-vaxers are able to play that conspiracy card.

    We need a new way.

  5. #5 PalMD
    July 19, 2008

    I’m listening, katie…

  6. #6 wazza
    July 19, 2008

    A film about them. Simple enough, you contrast videos of polio sufferers, the mass graves from the 1919 flu epidemic, etc with people telling us that vaccines aren’t important and that you can just get over measles and such.

    Make people fear the diseases again. And use Smallpox as a case in point of what can be done with vaccines.

  7. #7 Will K.
    July 19, 2008

    Part of the problem is a framing one. I’m not normally the kind of person that buys into the whole framing thing, but the anti-vax crowd has managed to use framing to their advantage. Between active media attention and misinformation, and a general reluctance to call them on the bullshit, I think they’ve managed to change the public perception of this conflict from pro-vaccine vs. anti-vaccine to pro-vaccine vs. anti-autism, striking an implication that the pro-vaccine considers autism a legitimate side affect to vaccinations.

    One factor that’s helped them along in this that needs to be turned around is proper journalism. Aside from that article in Time Magazine, how many times has the mainstream media been anything other than a pedestal for the anti-vax crowd to shout their propaganda from? The scientific community and the journalists have to form a tighter bond with one another to prevent things like this from seeping through the cracks (and being able to accurately and convincingly refute it when it does).

    But that’s just the two cents of someone who is neither a scientist nor a journalist, so take it for however much it’s worth.

  8. #8 Chuck
    July 19, 2008

    I’m sure if you do a film it would probably gloss over all those people who have and continue to suffer from ineffective influenza vaccines, like last year’s, and those still living with the very real adverse reactions to the smallpox vaccine.

  9. #9 Ross G.
    July 19, 2008

    Dear Palmd, I’m a pediatric oncologist, but I have recently worked for 5 years in primary care pediatrics. I was talking to the mother of a new leukemia child today. The mother is the type that asks every possible question, which isn’t always a bad thing. The child is having a birthday party in the hospital but can invite some friends from outside. The mom asked that some of the children have had no immunizations because the parents objected to vaccines and she asked me if it would pose a risk to him in his current state if they attended the party. My blood started to boil but I just told her that “If I were you I wouldn’t take the risk”. We recently had a varicella exposure situation on the unit and it was a real hassle. But this is really the crux of the matter. In some cases the “decision” not to have your child immunized literally threatens the live of others.
    I would really love to hire a personal injury lawyer when some school child is seriously harmed by a parent’s “decision” not to have their child immunized. Let me tell you that parent and the hoaxers that inspired him/her will end up on a street corner with a tin cup and a cardboard sign when we’re done with them.

  10. #10 Lucy
    July 20, 2008

    by default i agree with nothing this blog has to say. Yet, i do agree vaccinations are of paramount importance. there are certain things the medical community has done 100% correct to protect their citizens and this is one of them.

    if someone were to figure out another way to avoid hepatitis, polio, and all the other communicable diseases…i am listening. until then, this is a public safety issue.

  11. #11 HCN
    July 20, 2008

    Ross G. wrote ” I was talking to the mother of a new leukemia child today. The mother is the type that asks every possible question, which isn’t always a bad thing. The child is having a birthday party in the hospital but can invite some friends from outside. The mom asked that some of the children have had no immunizations because the parents objected to vaccines and she asked me if it would pose a risk to him in his current state if they attended the party.”

    Dr. G, my oldest son was not vaccinated for pertussis when he was an infant due to a history of seizures. At that time there was a pertussis epidemic in our county. I did actually ask for the vaccine status of any child he came into contact with. During the last few years, I have spoken to parents of children his age (high school, friends, sports, etc) and several did come down with pertussis. Considering the other health issues with the kid (like getting admitted to the hospital four times due to croup and a very severe heart condition)… I don’t feel at all bad about keeping him from unvaccinated children.

    You should tell that mother that her child is at risk for contracting diseases from under vaccinated children, and that she should tell those parents. Do not let them visit in the hospital, and definitely do not allow them near her child when he/she goes home!

    If you need more back-up, just print out this article:
    http://www.timesonline.co.uk/tol/news/uk/article1055533.ece

    (oh, by the way… I tend to react negatively when someone claims that measles or pertussis only kills “unhealthy” children… I usually ask them why a kid like mine with hypertrophic cardiomyopathy is not as deserving of like as their kid!)

  12. #12 HCN
    July 20, 2008

    Oh, rats! I did a spell check… so why did not see this until I hit “submit”… it is supposed to say ” usually ask them why a kid like mine with hypertrophic cardiomyopathy is not as deserving of LIFE as their kid!)”

  13. #13 varkam
    July 20, 2008

    I don’t mean to be a party pooper, but part of me thinks that another thing that the anti-vaxers have on their side is human nature. They’re uncovered a conspiracy, they’re fighting the good fight against nameless, faceless corporations and governments. There’s something that I think many people find inherently cool or rewarding in that.

    I agree that we need to do a better job spreading the word, I guess that’s one of the reasons I started blogging. It seems, though, that the MSM is already pretty much in the corner of the anti-vaxers at worst. At best, they are completely credulous when it comes to science. It’s as if they want to bend over backwards to give even the crappiest ideas equal time (and hence the appearance of being impartial) and equal merit. I mean, if I see Jenny on LKL one more time I think I’m going to scream. I think that grassroots advocacy is a great idea, and I’m not going to stop blogging…it’s just that…well…color me skeptical on the whole stemming the tide, thing.

  14. #14 daedalus2u
    July 20, 2008

    Ross, You make an excellent point, and people who are not properly vaccinated should be discouraged from visiting public places where they may expose vulnerable people to the preventable diseases they may carry.

    I think that hospitals should have warning signs at the entrance warning people who have not been vaccinated to stay away unless they are a patient, and then to inform their doctor of their vaccination status; for their own protection as well as for the protection of vulnerable patients.

    A large warning sign with information leaflets that can be picked up for more information. Ones that discuss the adverse effects of the dieases that vaccination prevents, such as the recent measles deaths. With a slogan like “public health is everyone’s responsibility”.

  15. #15 EDG
    July 20, 2008

    The crux of the ethical dilemma, for me, is for kids like HCN’s. There are good reasons not to vaccinate a very small number of kids with other health problems. Your decision to not vaccinate your healthy child puts his child — and many others — at risk. We don’t let people drive without licenses and insurance. We don’t let people engage in other high-risk behavior with the potential to harm others. Why do we tolerate this situation?

  16. #16 Chuck
    July 20, 2008

    “I think that hospitals should have warning signs at the entrance warning people who have not been vaccinated to stay away unless they are a patient”
    That warning applies more to patients then to visitors since patients are more endangered from extraneous complications then visitors.

  17. #17 Anonymous
    July 20, 2008

    “We don’t let people engage in other high-risk behavior with the potential to harm others.”

    The second and twenty first amendments both disprove that statement.

  18. #18 HCN
    July 20, 2008

    Chuck, many patients have significant medical reasons for not being vaccinated… like these kids:
    http://www.timesonline.co.uk/tol/news/uk/article1055533.ece

    If a family decides because of fear of the small tiny reaction from a vaccine to not vaccinate, then they should keep those children away from susceptible populations. That includes hospitals, anywhere with babies too young to be vaccinated (like the babies under a year old that got measles because an infected kid entered the doctor’s waiting room, or any baby too young to be vaccinated against pertussis) and anywhere there are the elderly.

    If they decide to totally skip the MMR, due to the incredible communicability of measles and the fact that it is infectious for at least a week before symptoms… then they should keep those children away everyone, especially hospitals, clinics, schools that have kids with immune problems, anywhere with babies too young to be vaccinated… etc. Just going on what happened to the two boys in the UK (see article) and the under age one kids in San Diego infected in a doctor’s waiting room.

    By the way, I am still waiting for someone to tell me what real scientific evidence there is that the MMR is riskier than measles (archpedi.ama-assn.org/cgi/content/full/160/3/302, encephalitis 1 in 1000, mental retardation 1 in 5000), mumps (www.cdc.gov/mmwr/preview/mmwrhtml/mm5520a4.htm, about two dozen orchitis, four deafened in less than 3000 cases), and rubella.

    I am not terribly convinced that there is any proof the MMR causes autism. It has been around since 1971, never ever contained thimerosal, and the only paper that tried to link it to autism was based on a dozen kids (most of whom were provided by the lawyer representing them in a lawsuit).

  19. #19 meshil
    July 21, 2008

    If a family decides because of fear of the small tiny reaction from a vaccine to not vaccinate, then they should keep those children aware from increasing populations
    =============================================================
    meshil


    Addiction Recovery North Dakota

  20. #20 Chuck
    July 21, 2008

    “If a family decides because of fear of the small tiny reaction from a vaccine to not vaccinate, then they should keep those children aware from increasing populations”

    No we should just prevent them from ever entering the country.

  21. #21 Chuck
    July 21, 2008

    “If a family decides because of fear of the small tiny reaction from a vaccine to not vaccinate, then they should keep those children away from susceptible populations. That includes hospitals,”

    Yet that does not happen along will vaccine preventable illness there are other infections and illness that propagated and spread within hospital. Is that the visitor’s fault or the medical professionals fault?

  22. #22 Denice Walter
    July 21, 2008

    In my quest to uncover the most egregious anti-vax websites,I’ve found one that demonstrates the incestuous relations between,shall we say, the various actors and reacters involved: NJ Coalition for Vaccination Choice.Also,following some links I came across: thinktwice.com, whose FAQ section examines methods for parents who, unhappy with that “new stylee immunity”-i.e. vaccination-want their kids to get immunity the old fashioned way: by getting the disease from other kids.Some are even willing to fly places to get the “real thing”.(My advice:”Don’t think twice”).Sites such as these illustrate the level of discourse going on.I try personally to counter this sort of thing by pointing people to educational, not entertaining, websites.

  23. #23 HCN
    July 21, 2008

    Chuck whined: “No we should just prevent them from ever entering the country.”

    Most of the folks spreading pertussis have never left this country. Your blocking the borders strategy has a significant flaw. See:
    http://www.metrokc.gov/health/immunization/newsstories.htm#pertussis

    Also, along with the actual scientific data showing that the MMR is more dangerous than measles, mumps and rubella: where is the actual scientific evidence that the DTaP is more dangerous than diphtheria, tetanus and pertussis.

    Chuck continued “Is that the visitor’s fault”… the visitor. If they are going to be a parasite and rely on herd immunity, they have absolutely no right to go into a place where there are people who MUST rely on herd immunity.

    By the way, on the many times my oldest was in the hospital, the ward he was in was next to an oncology ward. There were some severe restrictions on who can enter that ward.

    And yes, when my son was less than a year old I did restrict who he could be with. They had to be fully vaccinated.

  24. #24 Chu
    July 21, 2008

    HCN,

    How many cases of measles would there be in the USA if the index case of each outbreak had not been on foreign soil?

    Can you prove that all viruses and infections in hospitals are caused by visitors alone?

  25. #25 HCN
    July 21, 2008

    Strawman arguements, Chu.

    Yes, idiot… the measles all came from out of the country. But it spread to others, and it does not take much to make it endemic like it is in the UK. Do you need to be reminded of what happened between 1987 and 1991?

    But my issue has mostly been pertussis. Where is the evidence that pertussis is from across the borders. Pertussis actually kills more kids in the USA than measles right now. Where is the evidence that DTaP if more dangerous than pertussis.

    “Can you prove that all viruses and infections in hospitals are caused by visitors alone?”

    Can you be more stupid? Where did I even imply that?

  26. #26 Chuck
    July 21, 2008

    HCN,

    I don’t know if you can be more stupid because I never implied that you said anything. I would give credit where credit is due.

    Is the mortality rate for measles in the United States between 1987 and 1991 higher then the mortality rate for influenza during the same time period? I couldn’t find the mortality rate for the US during that time frame.

    You have your vaccine issues and I have mine.

  27. #27 HCN
    July 21, 2008

    Apples and oranges when you compare measles with influenza.

    And what is YOUR plan to reduce influenza? The virus mutates each year. Do you plan to have legislation written to make it stop mutating? Or do you plan to just restrict travel from where influenza originates?

    Compared to influenza, measles is easy to control. Its only vector is humans. With vaccination it could go the way of smallpox. But, alas… due to some lawyer funded “research” in the UK it is coming back.

    Honestly, your solutiong to measles is to restrict trave? Have you written your senators and representatives to restrict travel in and out of the USA to only those that have been vaccinated?

    How exactly would that work for pertussis, tetanus, Hib and hepatitis?

  28. #28 Nic
    July 22, 2008

    I think we just need to start a Science PAC and start funneling money into politics. Or start electing scientists. Have to beat them at their own game.

  29. #29 HCN
    July 22, 2008

    Chuck said “You have your vaccine issues and I have mine.”

    And I somehow manage to back mine up with real verifiable scientific literature (with the added bonus of having to spend several hours in the hospital emergency department, followed by days in the hospital with a very sick kid… and the kid was actually delivered by ambulance a couple of times… one of them because he might had had what is now a vaccine preventable disease).

    Where are yours?

    What real actual evidence do you have that the MMR vaccine (which has been around since 1971 and never contained thimerosal) is more dangerous than measles, mumps or rubella?

    What real actual evidence do you have that the DTaP vaccine is worse than pertussis, tetanus or diphtheria?

    And for fun… How about the HiB vaccine… or IPV?

    Got data?

    Do you have anything other than the apples and oranges comparison to the influenza vaccine? (which my kid gets early each year because of his genetic heard disorder)

    Oh, wait… some papers for you to chew on since I am allowed two URLs:
    http://archpedi.ama-assn.org/cgi/content/full/159/12/1136
    and
    http://archpedi.ama-assn.org/cgi/content/full/160/3/302

    Come on, show that the herd immunity you hope to protect your other kids is threatened by the fact that the USA does not check immunization records at the border! (by the way, I’ve lived where one had to carry immunization records at all times, or else the Guardia Nacional would drag you into a local clinic for an immediate Yellow Fever jab… do you really think this would pass in Congress?)

  30. #30 Chuck
    July 22, 2008

    “(with the added bonus of having to spend several hours in the hospital emergency department, followed by days in the hospital with a very sick kid… and the kid was actually delivered by ambulance a couple of times… one of them because he might had had what is now a vaccine preventable disease”

    BTDT for years. Vaccinated, Had the “Vaccinated preventable DISEASES” (Plural diseases, plural people)

  31. #31 Oldfart
    July 22, 2008

    Well, this thread certainly degenerated.

    I like the idea of the government getting involved with vaccination encouragement and I think the suggested horror video from past epidemics would be just the thing with the right announcer and the right tone of voice. The government also ought to be encouraging information about vaccinations (how they work, why we need them) in school health classes (they still have those, don’t they?)

    Since Obama is the likely new president (unless the Democrats really screw up), what is HIS views on this subject and what are the views of a Democratic congress on this subject. I’d almost be willing to bet that the anti-vaxers are primarily left wing as a lot of woo is left wing.

  32. #32 Tsu Dho Nimh
    July 22, 2008

    Chuch says” No we should just prevent them from ever entering the country.

    So you are saying that being fully vaccinated should be a requirement for entering the USA? GREAT! The San Diego outbreak was caused by an unvaccinated American citizen child who went to Switzerland and came back infected. Another in the midwest was caused by unvaccinated American citizen church group members returning from India – even thourgh they had been asked to stay in India until they were through the incubation period.

    They should have been required to show proof of vaccination to enter the country after being in a country where the disease is known to be acitve, just like it used to be for smallpox.

  33. #33 Chuck
    July 22, 2008

    “They should have been required to show proof of vaccination to enter the country after being in a country where the disease is known to be acitve, just like it used to be for smallpox.”

    Fully agree

  34. #34 Bre
    July 22, 2008

    I think the problem is that we have gone too far with all the vaccines. We vaccinate for everything. People see it as over kill. They dont want their kids to get 15 shots everytime they take them to the Dr. One is not so bad, five is overkill.

  35. #35 HCN
    July 22, 2008

    Okay, Bre, just tell us which of the following we should stop vaccinating for:

    measles
    mumps
    pertussis
    diphtheria
    tetanus
    HiB
    polio
    rubella
    varicella
    hepatitis
    meningococcal meningitis

    Your call, which ones do we eliminate? And since it has been historically shown that the disease returns when the vaccination is reduced (measles and mumps came back to Japan, diphtheria returned with deadly results to the former Soviet republics after the USSR broke up, pertussis always returns and still kills about a dozen babies per year in the USA, polio returned to Nigeria after some scaremongering there and people just “love” meningitis, see http://www.meningitis-angels.org/ ), just tell us which one you would like to see back in circulation.

    Which disease do you want back?

  36. #36 Melissa G
    July 23, 2008

    It isn’t 15 shots, Bre– it’s never more than 4 injections at a time, even though there are multiple vaccines in each one. Your kid can handle it.

  37. #37 Chuck
    July 23, 2008

    “Which disease do you want back?”

    Maybe if we stop the Chicken Pox vaccine, the incident of shingles would decrease? But science is still clueless and the jury is still out on that question.

  38. #38 HCN
    July 23, 2008

    Do you have a link to the paper that says if the varicella vaccine ends there would be a decrease in shingles?

  39. #39 PalMD
    July 23, 2008

    Data?? We don’t need no stinkin’ data!

  40. #40 Chuck
    July 23, 2008

    Do you have a link to the paper that says when varicella vaccine started, the incident of shingles didn’t increase afterwards?

  41. #41 HCN
    July 23, 2008

    Well, the data that is available is confusing. From:
    http://www.ncbi.nlm.nih.gov/pubmed/18419401? … there are confusing relationships between the vaccine and shingles.

    It says “In the United States, a varicella vaccination program was implemented in 1995. Since then, studies monitoring HZ incidence have shown inconsistent findings: 2 studies have shown no increase in overall incidence, whereas 1 study has shown an increase. Studies from Canada and the United Kingdom have shown increasing rates of HZ incidence in the absence of a varicella vaccination program.”

    It continues “Data suggest that heretofore unidentified risk factors for HZ also are changing over time.”

    Oh, like an aging population? Those of us who are baby boomers and had chicken pox during the 1950s up to the 1970s (or so) are the ones now getting shingles.

    I bet there is also an increasing need for reading glasses. Did the varicella vaccine also cause an increase in presbyopia?

  42. #42 Chuck
    July 23, 2008

    It continues “Data suggest that heretofore unidentified risk factors for HZ also are changing over time.” = justification for my “science is still clueless” statement.

    “Well, the data that is available is confusing”
    = justification for my “the jury is still out on that question” statement.

  43. #43 Dianne
    July 23, 2008

    HCN: Also confounding the vaccine/shingles issue, there are now more people living with immunosuppression of various sorts (HIV, bone marrow transplant, long term survivors of genetic errors in immunity), who are at increased risk of shingles. Given the confounders, a stable rate of shingles may suggest a decreased risk after vaccination. Any studies that control for age and immunosuppression out there?

  44. #44 Chuck
    July 23, 2008

    If the age of onset is younger then any study that controls for age would be biased.

  45. #45 PalMD
    July 23, 2008

    Chuck,your repeated demands that people prove a negative are tiresome.

  46. #46 HCN
    July 23, 2008

    Dianne, do what I do… go to http://www.pubmed.gov and plug in some magic search words. It is not that hard (though it seems a bit too difficult for Chuck).

  47. #47 Chuck
    July 24, 2008

    Asking for accurate data is tiresome, but it doesn’t seem to bother you or HCN does it PAL?

  48. #48 Chuck
    July 24, 2008

    HCN and PAL,

    Bull Math Biol. 1999 Nov;61(6):1031-64

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