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Does the (Flu) Vaccine Matter?
October 14, 2009 9:41 AM   Subscribe

In Does the Vaccine Matter?, Shannon Brownlee and Jeanne Lenzer discuss the history of vaccines and explore why "some flu experts are challenging the medical orthodoxy and arguing that for those most in need of protection, flu shots and antiviral drugs may provide little to none." In a related story (which condenses and provides a point-by-point summary of the original (with obvious bias)): "Flu vaccines revealed as the greatest quackery ever pushed in the history of medicine."
posted by torquemaniac (90 comments total) 6 users marked this as a favorite

 
*eyeroll*
posted by grubi at 9:46 AM on October 14, 2009 [3 favorites]


"Flu vaccines revealed as the greatest quackery ever pushed in the history of medicine."

I'm sorry, have they not heard of Trepaning or Homeopathy?
posted by Bathtub Bobsled at 9:49 AM on October 14, 2009 [8 favorites]


Upcoming Atlantic Rhetorical Question Article Headlines:

Has Anyone Ever Really Seen The Bottom Of The Ocean? Questioning The Dogma Of A Noninfinite Sea

What Exactly Occured In 2020? And How Did We Let It Happen? - A Look Back At The Future Of Indo-Chinese Nuclear Imperialism

What's So Good About Fruits And Vegetables, Anyway? One Rouge PhD Who Just Might Change Your Mind About Apples And Oranges

Would McCain Have Been Better? A Vexing Query By Thomas Friedman
posted by Damn That Television at 9:51 AM on October 14, 2009 [45 favorites]


Natural News is totally crackpot. When the media totally misrepresented one researcher and the Sunday Express had to retract a front page story - well, they think that some conspiracy is forcing her to change her story instead and are somehow getting to her.

It really puts out some astonishingly dangerous bullshit.
posted by edd at 9:53 AM on October 14, 2009 [6 favorites]


This kind of crap is the last thing we need during a pandemic.
posted by TrialByMedia at 9:56 AM on October 14, 2009 [2 favorites]


What was that quote about debates?
posted by setanor at 9:57 AM on October 14, 2009


Yeah, that's why I didn't renew my Atlantic subscription. 90% of the articles are all about contraindication. The other 10% read like cheap ripoffs of Harper's or New Yorker articles.

I'm sorry, have they not heard of Trepaning or Homeopathy?

Spoken like someone who had a bad session with the phrenologist. Still pissed he said your marriage prospects were grim?
posted by dw at 9:59 AM on October 14, 2009 [7 favorites]


I don't understand. The vaccine IS the virus (a dead version or so I understand), so what's the problem? Or do I not understand the flu vaccine's correctly?
posted by forforf at 10:01 AM on October 14, 2009


In a darkened room of a musty house, the Icepick Lobotomy looks at its ancient trophy and begins to weep.
posted by adipocere at 10:01 AM on October 14, 2009 [6 favorites]


"Flu vaccines revealed as the greatest quackery ever pushed in the history of medicine."
I'm sorry, have they not heard of Trepaning or Homeopathy?


Of course they have. See their article, Important for Swine Flu Epidemic: Homeopathy Successfully Treated Flu Epidemic of 1918.

You can't make this shit up.
posted by grouse at 10:01 AM on October 14, 2009 [18 favorites]


I'm sorry, have they not heard of Trepaning or Homeopathy?

Oh, they've heard of homeopathy. Believe me, they've heard of homeopathy.
posted by gurple at 10:02 AM on October 14, 2009 [3 favorites]


Fuck naturalnews.com and all the other blithering idiots who babble on and on about that nonsense. Just because some people are stupid and easily led doesn't give you a right to lie to them.
posted by Inspector.Gadget at 10:02 AM on October 14, 2009 [1 favorite]


The Atlantic article was informative, but the link to registration-required Natural News was pointless and annoying. It's unfortunate that people are likely to focus on the inane sensationalism of that piece of crap rather than the points raised in the Atlantic article: that flu vaccine trials are non-existent or possibly flawed. Interesting that even in cases of the wrong flu vaccine being prepared for a particular season, mortality does not increase, even though those vaccines are effectively worthless.
posted by oneirodynia at 10:05 AM on October 14, 2009 [3 favorites]


"Flu vaccines revealed as the greatest quackery ever pushed in the history of medicine

Trust me, Mike the Health Ranger knows more about this than you could possibly imagine.
posted by clearly at 10:05 AM on October 14, 2009 [5 favorites]


Some of that sounds reasonable - like pointing out the statistics and the lack of testing. That said, getting the vaccine doesn't seem to do any harm, looks like any harm comes from getting the vaccine and then not doing anything else.
posted by dilettante at 10:10 AM on October 14, 2009


IANAD but for me the issue is not vaccinations themselves but mandatory vaccinations. So, not medical but political, I guess. Am I the only one who thinks there's something very spooky about injecting something into someone against his or her will? Even if it's in their very best interests, that sets an ugly authoritarian precedent.

The argument is that the real value of vaccinations is only evident when 95%+ of the population has them. Herd immunity, I think it's called. Therefore, it's a good idea to give them to everybody. Historically, haven't "good ideas" that require such a high degree of compliance been marginalized as utopian and unrealistic?

I'm just posting this here because it seemed relevant to the discussion to present an alternate viewpoint apart from the science vs. quackery angle.
posted by The Winsome Parker Lewis at 10:11 AM on October 14, 2009 [3 favorites]


Oh, yay, another herd-immunity discussion is about to ensue. This should be fun.
posted by mr_crash_davis mark II: Jazz Odyssey at 10:13 AM on October 14, 2009 [1 favorite]


Sorry, I'm new here. Has this been beaten to death already?
posted by The Winsome Parker Lewis at 10:14 AM on October 14, 2009


YThe Winsome Parker Lewis: "IANAD but for me the issue is not vaccinations themselves but mandatory vaccinations. "

They're not mandatory. But then again, it's not mandatory for doctors to take in your sick kid if they find out he's not had his shots because his dad's an idiot.
posted by notsnot at 10:17 AM on October 14, 2009


IANAD but for me the issue is not vaccinations themselves but mandatory vaccinations.

Since mandatory influenza vaccinations, except for health care workers, are not being discussed, you, in fact, have no issue.
posted by grouse at 10:19 AM on October 14, 2009 [2 favorites]


Well, yeah. I've heard more discussions of making them mandatory since H1N1 hit and thought it might be relevant. But totally a side tangent. :-)
posted by The Winsome Parker Lewis at 10:22 AM on October 14, 2009


I just spent ten minutes on that site and my rage levels reached an all-time high. This anti-vaccination article is very frustrating, but I'm used to seeing this sort of stuff from fervent anti-vaxxers; if you remember that anti-vaccination stance is now a faith position rather than a reasoned one, these astonishing leaps of bad logic, self-deception and doublethink are still depressing but no longer surprising.

But then a link at the bottom of the page caught my eye and caught me completely wrong-footed: Cancer is not disease, it's a survival mechanism. They're claiming that cancer is not a disease, that the cells are instead symptoms of some survival mechanism invoked by the body in response to certain stresses. It's like the HIV/AIDS denialist morons, except they're saying that TUMOURS are healthy?

They take the despicable approach of asking reasonable questions with very well-known answers (e.g. "why do most cancers disappear without treatment"*) then pretending that the answers are unknown, and that lack of an answer somehow supports their position. I happen to be quite well informed about the biology underlying cancer formation and progression so I can spot the half-truths, lies and what I can only assume is wilful ignorance, but most people haven't had that education. And many people aren't as good as mefites at spotting the gaping logical fallacies. The idea that a frightened cancer patient might come across this dangerous bullshit and reject their medication is terrifying.

The people running this site are creating a direct hazard to people's health by spreading these lies. They're either deliberately lying or criminally incompetent. Fuck free speech, this site needs to be shut down before they kill (more?) people.

*without getting too detailed, there are all sorts of systems within the cell set up to say "Oh, I'm dividing! Am I getting the right growth signals from the rest of the body to confirm that it wants me to divide? Is my DNA completely intact? Do I have enough resources to pull this off without causing damage?" and so on. If any of the answers are no, the cell commits suicide. There are further systems, e.g. some of your immune cells can spot some developing cancers and either order the cancer cells to commit suicide or kill them directly. Mutations of the type that can lead to cancer are actually pretty common events, but our cells are exquisitely set up to stop cancers before they become a problem. Of course it's not a perfect system, but it is very, very good. How these systems work is known in astonishingly fine detail, give or take some sketchy patches. It's just that the detailed explanation is too long and requires to much attention to be used as a compelling rhetorical flourish.
posted by metaBugs at 10:24 AM on October 14, 2009 [11 favorites]



Sorry, I'm new here. Has this been beaten to death already?


Nope, died of Swine Flu.
posted by furiousxgeorge at 10:27 AM on October 14, 2009 [1 favorite]


The argument is that the real value of vaccinations is only evident when 95%+ of the population has them. Herd immunity, I think it's called. Therefore, it's a good idea to give them to everybody. Historically, haven't "good ideas" that require such a high degree of compliance been marginalized as utopian and unrealistic?

how do you think we got rid of Smallpox

do you think that shit just disappeared on its own
posted by Damn That Television at 10:27 AM on October 14, 2009 [24 favorites]


The Atlantic article was quite interesting, thank you. (I too wish you had left off the last link, which really has nothing to do with the arguments in the first.)

Shannon Brownlee, one of the authors, has a pretty well-respected book out called Overtreated, which has been on my Amazon wishlist for a while. It's about evidence-based medicine and whether one of the root causes of high health care costs in the U.S. is the use of so many treatments that aren't really based in solid findings. Given that background, it's pretty interesting to read her take on the evidence behind the efficacy of the flu vaccine.

This passage from the article seems pretty in line with that work:

The annals of medicine are littered with treatments and tests that became medical doctrine on the slimmest of evidence, and were then declared sacrosanct and beyond scientific investigation. In the 1980s and ’90s, for example, cancer specialists were convinced that high-dose chemotherapy followed by a bone-marrow transplant was the best hope for women with advanced breast cancer, and many refused to enroll their patients in randomized clinical trials that were designed to test transplants against the standard—and far less toxic—therapy. The trials, they said, were unethical, because they knew transplants worked. When the studies were concluded, in 1999 and 2000, it turned out that bone-marrow transplants were killing patients. Another recent example involves drugs related to the analgesic lidocaine. In the 1970s, doctors noticed that the drugs seemed to make the heart beat rhythmically, and they began prescribing them to patients suffering from irregular heartbeats, assuming that restoring a proper rhythm would reduce the patient’s risk of dying. Prominent cardiologists for years opposed clinical trials of the drugs, saying it would be medical malpractice to withhold them from patients in a control group. The drugs were widely used for two decades, until a government-sponsored study showed in 1989 that patients who were prescribed the medicine were three and a half times as likely to die as those given a placebo.

Of course, it seems like the question is really whether the flu vaccine prevents *mortality*, not whether it works at all, given that most of those who die of the seasonal flu are the elderly and immuno-compromised who have the lowest chance of mounting any immune response to the vaccine itself. I got the flu shot a couple of weeks ago, and am planning on getting the swine flu vaccine in November, not so much because I'm worried about dying but because I have a cool vacation planned and really don't want to run through my vacation days being sick. I would guess that a not-insignificant number of 20- and 30-year-olds getted vaccinated for similar reasons (to prevent passing it on to someone else, to avoid spending a week in bed, etc).
posted by iminurmefi at 10:31 AM on October 14, 2009 [3 favorites]


The idea that a frightened cancer patient might come across this dangerous bullshit and reject their medication is terrifying.

This already happens:
Against all evidence to the contrary, she continued to refuse any form of “conventional medicine.” She still believed that her ” healer” could save her life, even though she now had a large, bleeding, stinking mass in her breast stuck to her chest wall that had three years ago been a pea-sized cancer that could have easily been excised with a small surgical procedure. She was well on her way to dying in the horrific way that so many women died of this disease 100 years ago.
posted by grouse at 10:32 AM on October 14, 2009 [3 favorites]


Linking that Natural News article was an unfortunate choice. Condensing the facts of an article from a perspective of obvious and unpopular (and, not to dance around the point, demonstrably irrational) bias is not a value-add.

The Atlantic article on the other hand is worth reading and the people who are dismissing this argument without any sort of a real defense either didn't bother reading it or aren't capable of understanding it. The writers (particularly Brownlee) have real credentials as medical journalists (though they exhibit in their backgrounds biases of their own that have to be taken into consideration) and the people they are citing are not run-of-the-mill crackpots, and their arguments are rational and based in firm principles of science. Which is not to say they are correct, but they are worth keeping in the debate.

It is possible and desirable to to study and better understand the real benefits of flu vaccination without discouraging people from being vaccinated. I find the conclusions of this article a little specious - I think they make a reasonable claim that there are sufficient doubts about the quality of the studies that promote the efficacy of the flu vaccine to warrant looking harder at the data. On the other hand, their is basically no apparent attempt to engage any real dissent to this case: they basically present a scenario where the entirety of the medical consensus on the benefits of vaccination consists of doctors with fingers in their ears going "nyah nyah nyah."

And when it comes to critiquing any negative impact of widespread vaccination their case is really slight. Basically it boils down to "vaccinating makes us feel invulnerable and not wash our hands and not stay home when we're sick" There's some sort of intimation of better ways of dealing with the flu that reliance on vaccination and post-infection drug treatments is keeping us from developing, but there's no meat whatsoever on the bones of that argument. They're critiquing a medical consensus by attacking the statistical rigor of the studies its based on but then justifying the supposed gravity of the putative error by arguments that are purely rhetorical, without a shred of hard science behind them, propped up with a few stories of alternative methods of dealing with the flu that are purely anecdotal.
posted by nanojath at 10:33 AM on October 14, 2009


"getted vaccinated"--what? I swear, English is my first language. I obviously need more coffee..
posted by iminurmefi at 10:33 AM on October 14, 2009


Damn That Television, it was sucked out by leeches. Right now, the medical establishment is against that natural cure because you can grow leeches in your backyard for free.

Besides, the smallpox vaccine is made with the vaccinia virus, AKA cowpox. Do you really want your government using diseases meant FOR COWS to immunize you? I'm writing my senator to tell him I'm not a heifer, and I'm sure as hell not a pig, either.
posted by mccarty.tim at 10:33 AM on October 14, 2009


This'll probably make no dent whatsoever in the how-dare-they-question-SCIENCE! snark herein, but the Atlantic piece is actually a well-reported survey of the state of the SCIENTIFIC debate, which in no way appears to support the out-of-hand dismissals in this thread.

Here's a better pull quote (from the Atlantic story itself rather than that spittle-soaked rant at Natural News):
[W]hile other flu researchers may not like what Jefferson has to say, they cannot ignore the fact that he knows the flu-vaccine literature better than anyone else on the planet. He leads an international team of researchers who have combed through hundreds of flu-vaccine studies. The vast majority of the studies were deeply flawed, says Jefferson. “Rubbish is not a scientific term, but I think it’s the term that applies.” Only four studies were properly designed to pin down the effectiveness of flu vaccine, he says, and two of those showed that it might be effective in certain groups of patients, such as school-age children with no underlying health issues like asthma. The other two showed equivocal results or no benefit.

Flu researchers have been fooled into thinking vaccine is more effective than the data suggest, in part, says Jefferson, by the imprecision of the statistics. The only way to know if someone has the flu—as opposed to influenza-like illness—is by putting a Q-tip into the patient’s throat or nose and running a test, which simply isn’t done that often. Likewise, nobody really has a handle on how many of the deaths that are blamed on flu were actually caused by a flu virus, because few are confirmed by a laboratory. “I used to be a family physician,” says Jefferson. “I’ve never seen a patient come to my office with H1N1 written on his forehead. When an old person dies of respiratory failure after an influenza-like illness, they nearly always get coded as influenza.”

There’s one other way flu researchers may be fooled into thinking flu vaccine is effective, Jefferson says. All vaccines work by delivering a dose of killed or weakened virus or bacteria, which provokes the immune system into producing antibodies. When the person is subsequently exposed to the real thing, the body is already prepared to repel the bug completely or to get rid of it after a mild illness. Flu researchers often use antibody response as a way of gauging the effectiveness of vaccine, on the assumption that levels of antibodies in the blood of people who have been vaccinated are a good predictor—although an imperfect one—of how well they can ward off the infection.

There’s some merit to this reasoning. Unfortunately, the very people who most need protection from the flu also have immune systems that are least likely to respond to vaccine. Studies show that young, healthy people mount a glorious immune response to seasonal flu vaccine, and their response reduces their chances of getting the flu and may lessen the severity of symptoms if they do get it. But they aren’t the people who die from seasonal flu. By contrast, the elderly, particularly those over age 70, don’t have a good immune response to vaccine—and they’re the ones who account for most flu deaths. [. . .]

In Jefferson’s view, this raises a troubling conundrum: Is vaccine necessary for those in whom it is effective, namely the young and healthy? Conversely, is it effective in those for whom it seems to be necessary, namely the old, the very young, and the infirm? These questions have led to the most controversial aspect of Jefferson’s work: his call for placebo-controlled trials, studies that would randomly give half the test subjects vaccine and the other half a dummy shot, or placebo. Only such large, well-constructed, randomized trials can show with any precision how effective vaccine really is, and for whom.
RTFA, folks. It doesn't support the Natural News hyperbole, but ain't quackery, either.
posted by gompa at 10:36 AM on October 14, 2009 [5 favorites]


A science vs. homeopathy argument won't draw the handful of MeFi quacks out of the woodwork. We all pretty much believe in the efficacy of modern medicine, and those of us with kids probably take them to the doc to get their shots.

However, during the Ford administration, one perfectly healthy young friend of mine got a flu shot and it took him a couple of decades to get out of his wheelchair and learn how to talk again. I know, he's an unusual case, but a friend's tragedy is more convincing to me than a boatload of studies, since I am an irrational human being. I will not be getting a shot.

Then there is this study, "still under peer review," not from The Natural News.
posted by kozad at 10:38 AM on October 14, 2009 [1 favorite]


From Homeopathy Successfully Treated Flu Epidemic of 1918: A system of medicine based on the principles of "like cures like," ... isn't that what flu vaccines are? Like (dead/ dying/ modified virus) bolsters your system against like (fully living virus). Anyhow, I also read these backwards (last link first), which was a mistake. The first link really is interesting.

Clips of interest from the Atlantic article:
Jackson’s findings showed that outside of flu season, the baseline risk of death among people who did not get vaccinated was approximately 60 percent higher than among those who did, lending support to the hypothesis that on average, healthy people chose to get the vaccine, while the “frail elderly” didn’t or couldn’t.
...
In 2004, for example, vaccine production fell behind, causing a 40 percent drop in immunization rates. Yet mortality did not rise. In addition, vaccine “mismatches” occurred in 1968 and 1997: in both years, the vaccine that had been produced in the summer protected against one set of viruses, but come winter, a different set was circulating. In effect, nobody was vaccinated. Yet death rates from all causes, including flu and the various illnesses it can exacerbate, did not budge.
And even though the percentage of people over age 65 in the U.S. and Canada who have gotten vaccinated has increased from 15% to 65%, death rates among the elderly during flu season have increased rather than decreased. On the flip, there are plenty of reasons this could be the case (elderly are less healthy due to change in diet, the flu is more deadly, the flu spreads farther and faster, etc).

I understand the fear that studying a "known good" when someone needs treatment is a scary thing, but it seems like very few things are really known and many things are assumed or appear better based on limited experiences.
posted by filthy light thief at 10:39 AM on October 14, 2009


Sorry for ignoring the actual meat of the post - it looks interesting. I was just too shocked and angry at the naturalnews site to think straight.

The Winsome Arthur Lewis - The argument is that the real value of vaccinations is only evident when 95%+ of the population has them. Herd immunity, I think it's called. Therefore, it's a good idea to give them to everybody. Historically, haven't "good ideas" that require such a high degree of compliance been marginalized as utopian and unrealistic?

Without getting into the politics of it, this can be and has been done. The mass vaccination campaign against smallpox eradicated the virus from the planet, save the freezers of a few research labs. We almost got Polio too - gone from Europe, Asia, the Americas, Australia. Unfortunately a few African states started being beset by rumours that the vaccination campaigns were some sort of American/Western plot and vaccination compliance went down, letting the disease get a new foothold. Now we're back up to a large patch of the continent having endemic infection and/or regular outbreaks.

So, yes. With a little effort we can cover a country, with more effort we can manage a continent. We've managed the whole world once, and got close a second time.

Whether a society should be able to decide that all of its members must be vaccinated is a whole other can of worms that has come up a lot on Metafilter over the past few months.
posted by metaBugs at 10:41 AM on October 14, 2009


And when it comes to critiquing any negative impact of widespread vaccination their case is really slight...They're critiquing a medical consensus by attacking the statistical rigor of the studies its based on but then justifying the supposed gravity of the putative error by arguments that are purely rhetorical, without a shred of hard science behind them

Not that I totally disagree with you, but their argument reminded me a lot of the FPP about Dr. Edward Green of Harvard who believes that distributing condoms in Africa is making the AIDS problem worse: if you give people a false sense of lowered risk when in actually their risk hasn't declined or has only declined a small amount, they'll act in riskier ways that have the net effect of making themselves worse off. Wasn't there some empirical evidence that Dr. Green had to back that up? (It's been too long since I read the links to remember.)

That's the parallel that leapt to mind, anyway.
posted by iminurmefi at 10:42 AM on October 14, 2009


"Yet some top flu researchers are deeply skeptical of both flu vaccines and antivirals."

I come to the blue for discussion and links that's a little more intelligent than this, pardon my french, complete and fucking utter bullshit. The internet is full of homeopaths, crystal healers, ostracized cranks, and pseudoscientific conspiracy theorists of all stripes. Why do we have to contaminate MeFi with their ignorance and thereby legitimize whatever BS they're selling?

If someone you know doesn't think flu vaccines are effective then they clearly lack a basic understanding of how the immune system and vaccines work.

In case anyone here really is so naïve as to entertain this sort of nonsense, go here and read what the real doctors (you know the ones that went to school for twelve plus years to have the right to say they actually know what they're talking about) have to say about this.
posted by inoculatedcities at 10:47 AM on October 14, 2009 [7 favorites]


From the Atlantic article:
Only four studies were properly designed to pin down the effectiveness of flu vaccine, he says, and two of those showed that it might be effective in certain groups of patients, such as school-age children with no underlying health issues like asthma. The other two showed equivocal results or no benefit
...

Unfortunately, the very people who most need protection from the flu also have immune systems that are least likely to respond to vaccine. Studies show that young, healthy people mount a glorious immune response to seasonal flu vaccine, and their response reduces their chances of getting the flu and may lessen the severity of symptoms if they do get it. But they aren’t the people who die from seasonal flu.
This isn't an indictment of the efficacy of the flu vaccine, it merely says that the people most likely to die from the flu (elderly, weak immune systems, already sick) actually do die even after they have been vaccinated because their immune systems are less likely to produce the desired result: the creation of antibodies from a weakened virus for future immunity to that virus. The most pertinent sentence in that paragraph is this:

"Studies show that young, healthy people mount a glorious immune response to seasonal flu vaccine, and their response reduces their chances of getting the flu and may lessen the severity of symptoms if they do get it."

The flu vaccine doesn't prevent the death of people who are likely to die from the flu anyway, but it does negate and or lessen the symptoms of those "young healthy people" (unbiased: most people) who are at risk of contracting seasonal flu.

Perhaps I am biased though, a week before the swine flu vaccine was available on my campus, I was diagnosed with what was likely the swine flu and spent 70+ hours in the fetal position with alternating fever and chills, a splitting headache, cough, and soreness in every muscle in my body. Being a healthy 24 year old, I may not have been at risk of death from influenza, but that does mean that I would not have benefited from a vaccine, or that vaccines are "quackery" or that citizen journalists writing about alternative medicine have any sort of authority when writing about a proven mechanism of treatment.
posted by clearly at 10:49 AM on October 14, 2009 [5 favorites]


Of course, it seems like the question is really whether the flu vaccine prevents *mortality*, not whether it works at all, given that most of those who die of the seasonal flu are the elderly and immuno-compromised who have the lowest chance of mounting any immune response to the vaccine itself.

OK, see, here's part of the damn problem with this whole thing. There are TWO vaccines -- the injected vaccine, which is killed flu virus, and the inhalable vaccine (aka FluMist), which is live but attenuated flu virus.

You DO NOT give the latter vaccine to anyone with a dodgy immune system -- pregnant women, people over 50, etc. You give them the INJECTED vaccine with the DEAD viruses. (In fact, some docs don't even like giving FluMist to people who come in contact with the immunocompromised -- just in case.)

The worst thing that could happen with the injected virus in older people is that the immune system doesn't respond to the dead virus. But if that's happening, it's likely the next cold will probably kill them just as much as the flu.

I think the thesis that Too Much Medicine Is Bad therefore The Flu Vaccine Is Bad is faulty. With cases like cancer treatment, you're caught between evidence-based medicine and the fact the patient is dying and you have to do something. If the patient dies, it may have everything or nothing to do with your treatment. The fiasco in the UK with the cervical cancer vaccine -- girl drops dead after getting the vaccine, OH NO THE VACCINE KILLS, oh wait undiagnosed tumor never mind please stop panicking oh crap -- is a perfect example of this sort of contradiction played out in the public.

I agree with her that we have too much medicine. But saying the flu vaccine is the problem is faulty given the evidence we do have that it works for vulnerable populations.
posted by dw at 10:51 AM on October 14, 2009


A chick I work with in all seriousness told me the reason she's not getting vaccinated is because that's how they turned people into zombies in the remake of "Invasion of the Bodysnatchers."
posted by Ruthless Bunny at 11:01 AM on October 14, 2009 [1 favorite]


And yeah, this line:

Studies show that young, healthy people mount a glorious immune response to seasonal flu vaccine

should immediately raise a red flag, given it was those glorious immune responses that probably killed so many young people during the 1918 pandemic.

We've seen a number of deaths of perfectly healthy young adults. A 16 year old in Tulsa, for example, died from H1N1 -- and had no known underlying health issues. His immune system appears to have just gone out of control (though we may not know for sure until the health department completes its tests).

And even in those who mount those "glorious immune responses," it's still a bear. Everyone I've known who's had it describes it as multiple days of pure misery.
posted by dw at 11:03 AM on October 14, 2009 [4 favorites]


This'll probably make no dent whatsoever in the how-dare-they-question-SCIENCE! snark herein, but the Atlantic piece is actually a well-reported survey of the state of the SCIENTIFIC debate, which in no way appears to support the out-of-hand dismissals in this thread.

The out-of-hand dismissals are almost entirely related to the Natural News link. Including it was a poor choice, but I feel no need to suppress responses to the insane link just because there is another link as well.

they basically present a scenario where the entirety of the medical consensus on the benefits of vaccination consists of doctors with fingers in their ears going "nyah nyah nyah."

I think this might be a little sensational as well, and perhaps inaccurate. The quotation from a review of Jackson's article says, "To accept these results would be to say that the earth is flat!" Having been on both sides of the peer-review process, I have little doubt that there were probably many other comments in the review questioning various parts of the methodology (why? because there almost always are, even for the best studies), but they cherry-picked the conclusion. To say the article was ignored is totally inaccurate, since it has been cited several times by commentary and reviews in prestigious journals such as The New England Journal of Medicine, the British Medical Journal. It also ignores the technical commentary by other authors on the methodology of this article, not all of it positive.

My conclusions:posted by grouse at 11:04 AM on October 14, 2009 [3 favorites]


Well, people dumb enough to believe this junk are going to die in greater numbers than rational people, resulting in fewer children from the dumb folks, which makes our gene pool just a little smarter going forward. So in a way, these junk science websites are enhancing humanity, albeit not in the way they might think.
posted by jamstigator at 11:05 AM on October 14, 2009 [1 favorite]


dw, I don't understand how the difference between attenuated virus and dead virus is relavent to their argument. Their argument is that we're pouring all of our resources into vaccines and antivirals to help prevent disaster in the event of a pandemic (and, to a lesser extent, pouring a lot of resources into vaccinating the elderly every year for seasonal flu). If those treatments are not actually preventing mortality in the elderly, because an immune system response is not being triggered, the "worst thing that could happen" isn't just that it doesn't work. That may be true on the individual level, but on the societal level you need to take into account opportunity costs: the money and effort put into pushing the flu vaccine is money and effort *not* being spent on other measures (e.g., teaching people about social isolation techniques, pushing for legislation that mandates paid leave for any worker with the flu, or even just pushing the young up to the front of the flu shot line [as they do in Japan, I believe] because they are the most likely vectors of infection for the rest of us).

To make a broad generalization, many of the problems in our medical system today are a result of applying risk/benefit analysis on the individual level ("well, it definitely won't hurt, even if we don't have good evidence that it will help, it's better to be on the safe side") and never stepping back to consider the risk/benefit analysis from the social or policy perspective. Once you make the latter step, you have to start caring about opportunity costs (doing an imaging study for a patient with lower back pain might not hurt that patient, but the explosion in imaging over the past 10 years has been a major component of medical cost inflation which is directly related to the rise in uninsurance rates, which is a factor in causing excess deaths).

I think those questions--is our current approach to preventing flu deaths supported by evidence, and if not, what sorts of harms might that create because we're forgoing other approaches--are really important to ask. Even if asking them means we risk some people deciding not to get a flu shot.
posted by iminurmefi at 11:11 AM on October 14, 2009 [3 favorites]


"Flu vaccines revealed as the greatest quackery ever pushed in the history of medicine."

This is the vilest use of hyperbole ever uttered in the history of human communication.
posted by nickmark at 11:17 AM on October 14, 2009 [6 favorites]


The reason she's not getting vaccinated is because that's how they turned people into zombies

Nah, they just gave them tax rebate checks and told them they could keep all the guns they wanted.
posted by rokusan at 11:28 AM on October 14, 2009 [1 favorite]


This is pernicious, loathsome shit. Vaccinations are a societal as well as a personal good, which means that the people spouting off these ludicrously underdeveloped positions hurt far more people than just those who listen to them.

The important concept, as other people have mentioned, is herd immunity: if you vaccinate enough members of a population, you afford the entire population protection. This is a fantastically beneficial statistical phenomenon, because it shields people with weak immune system who can't safely take vaccines and are more vulnerable to contagion in the first place.

The thing is, you have to vaccinate enough people. If enough parents stop getting their kids shots, if the population drops beneath the herd immunity threshold...

Hey, look! Pertussis is coming back to America! Thanks a lot, assholes.
posted by Iridic at 11:35 AM on October 14, 2009 [1 favorite]


It's not all bad news though. On the upside, Simon Singh has just won the right to appeal against the voodoo-peddling charlatans who wanted to silence him.
posted by PeterMcDermott at 11:40 AM on October 14, 2009 [2 favorites]


The thing is, you have to vaccinate enough people. If enough parents stop getting their kids shots, if the population drops beneath the herd immunity threshold...

There is a danger in this thinking. For example, I have never had a flu shot, and I have not had the flu since I was a kid, despite being around adults and kids who've had it. But I may have been carrying the flu virus which I passed on to someone else. Perhaps if I had a shot, that virus would have been killed and not passed on.

But if there is a non-zero risk to my health from getting the shot (side effects, whatever), the temptation from a policy standpoint is to balance my risk against that of spreading. This balance will always tip against me. But my self-interest lies in assessing the risk for myself.

You cannot, and ethically speaking should not, force, coerce, or encourage people to undergo medical procedures that benefit society when the risk of the procedure is bourne by the patient alone.
posted by Pastabagel at 11:48 AM on October 14, 2009 [1 favorite]


Summary for those with little time:

The first link: A thoughtful Atlantic article well worth reading, the main point - they've never done placebo-controlled trials of the flu vaccine so we don't really know if it works or not.

The second link is hysterical in both senses of the word. Skip.
posted by storybored at 11:48 AM on October 14, 2009


What's So Good About Fruits And Vegetables, Anyway? One Rouge PhD Who Just Might Change Your Mind About Apples And Oranges

THEY CONTAIN FRUCTOSE!!!!
posted by delmoi at 12:01 PM on October 14, 2009 [2 favorites]


Go on and believe this, y'all, it'll just make it easier for me to get my H1N1 shot.
posted by fiercecupcake at 12:13 PM on October 14, 2009


Did I mention *eyeroll* yet? I did?

Just checking.
posted by grubi at 12:20 PM on October 14, 2009


Well, people dumb enough to believe this junk are going to die in greater numbers than rational people, resulting in fewer children from the dumb folks, which makes our gene pool just a little smarter going forward.

My dad has been making this point about anti-vaxxers for a while now. The problem is that while people who are dumb enough to believe this junk are dying, they're going to take some innocent people (many of them children) with them. And, while they themselves die from whatever voodoo they use in place of real medicine, the ideas continue infecting more people. Really, it's a net loss.
posted by lexicakes at 12:32 PM on October 14, 2009


You cannot, and ethically speaking should not, force, coerce, or encourage people to undergo medical procedures that benefit society when the risk of the procedure is bourne by the patient alone.

So an immune disease carrier who wishes to avoid treatment, like Typhoid Mary, should be free to do as they please?
posted by lupus_yonderboy at 12:36 PM on October 14, 2009 [3 favorites]


"Flu vaccines revealed as the greatest quackery ever pushed in the history of medicine."

Do you have a minute? I would like to talk to you about an amazing new tonic I have developed!
posted by clearly at 12:38 PM on October 14, 2009 [1 favorite]


There is a danger in this thinking. For example, I have never had a flu shot, and I have not had the flu since I was a kid, despite being around adults and kids who've had it. But I may have been carrying the flu virus which I passed on to someone else. Perhaps if I had a shot, that virus would have been killed and not passed on.

Well, it's kind of a different story with the flu than it is with pertussis or measles... the number of mutations that crop up in flu viruses over the course of a single flu season is really high, as compared to the diversity of, say, smallpox. Mortality is also much lower. That's not to say herd immunity isn't still a consideration, but since standard flu strains aren't especially dangerous to normal, healthy individuals, and since getting vaccinated in September is probably not going to protect you from January's variant of the flu, I'd say it's conscionable to skip the flu vaccine.

Skipping MMR vaccinations for your children, on the other hand, should be grounds for having your kids taken away.

You cannot, and ethically speaking should not, force, coerce, or encourage people to undergo medical procedures that benefit society when the risk of the procedure is bourne by the patient alone.

The problem here is that people aren't performing the correct cost-benefit analysis, because the dangers are being blown out of proportion. Vaccinations demonstrably don't cause autism or GBS, but you'd never know it from reading an article in Time magazine, because lunatic fringe positions are inexplicably getting way more than their share of airtime. The chance of a negative outcome from getting any vaccine is tiny, and compared to the harms you impart on everyone around you by not getting the important ones, it's pretty damned insignificant.
posted by Mayor West at 12:42 PM on October 14, 2009 [2 favorites]


dw, I don't understand how the difference between attenuated virus and dead virus is relavent to their argument.

No, it does make a difference.

If those treatments are not actually preventing mortality in the elderly, because an immune system response is not being triggered, the "worst thing that could happen" isn't just that it doesn't work.

The worst thing that could happen with the killed vaccine is nothing. The worst thing that could happen with FluMist is getting the flu from FluMist. That was the point I was making.

That may be true on the individual level, but on the societal level you need to take into account opportunity costs

No, I am. You're believing flu prevention is some sort of zero-sum game -- if I spend $1 on developing a vaccine that's $1 I don't have for prevention. The problem is, of course, that prevention is dirt cheap compared to developing a vaccine. Get the message to the media, throw up a website, a few Ad Council commercials, print up some pamphlets, voila.

At the same time, you have to take into account the costs of flu with the vaccine. $2B to vaccinate 1/3 of the population is cheap compared to having to hospitalize 500,000 additional people due to H1N1 -- at an average cost of $10K per patient, that's $5B in additional medical costs. And that's not counting the cost of the 90K additional deaths.

To make a broad generalization, many of the problems in our medical system today are a result of applying risk/benefit analysis on the individual level ("well, it definitely won't hurt, even if we don't have good evidence that it will help, it's better to be on the safe side") and never stepping back to consider the risk/benefit analysis from the social or policy perspective.

While this is true, I think you have to distinguish between, say, a $15 lab test that would just confirmed what's bleedin' obvious in the patient vs a $15 vaccine. In the former case, you have the problem of patients demanding more care, doctors being defensive or not embracing best practices, and a legal system that leans conservative with things like this. In the latter case, there's a 70% chance you're eliminating a disease vector with a 1:10,000 chance of a serious side effect.

In that light, the vaccine, given to the correct cohorts of people (the young, the old, pregnant women, first responders and medical personnel, anyone who has frequent contact with vulnerable people who can't have the vaccine), makes perfect sense. The question blurs when you get to mass inoculation, but keep in mind that seven months ago this virus had a 2% kill rate -- 100 times normal flu and along the lines of 1918 H1N1. In the seven months hence we've now seen this virus has only a slightly higher mortality rate alongside a much higher morbidity rate, but the studies and evidence that have come since then took seven months to get here. If it really was killing at a 2% rate and we didn't accelerate the vaccine process, we probably wouldn't have an H1N1 vaccine before late spring, by which point we'd be facing a couple million dead in the US.

The problem with evidence-based medicine is that sometimes you can't wait for the evidence to all show up, especially when it comes to epidemiology.

I think those questions--is our current approach to preventing flu deaths supported by evidence, and if not, what sorts of harms might that create because we're forgoing other approaches--are really important to ask. Even if asking them means we risk some people deciding not to get a flu shot.

But then you're going to get caught in the same trap obstetrics is currently caught in -- medical research is difficult to impossible because you're gambling with human lives. You want to be the one shooting Grandma full of saline instead of vaccine?

The best thing you can do, honestly, is examine immunized populations vs. unimmunized ones. And I think we've done those studies (though I can't think where they are in PubMed) and they've shown effectiveness.

I do think we need to lay off the Tamiflu, though. I keep reading people getting it from their docs who have zero exposure to threatened populations. Let's leave it for the sick already.
posted by dw at 12:47 PM on October 14, 2009


The best thing you can do, honestly, is examine immunized populations vs. unimmunized ones. And I think we've done those studies (though I can't think where they are in PubMed) and they've shown effectiveness.

The linked article in the Atlantic actually talks about those studies a fair bit, and the conclusion (at least if the authors are not misrepresenting the main study that refutes them) is that the lower risk of death among the immunized population holds steady even outside of flu season--in fact, the risk of death diverges even further outside of flu season for the immunized--which is exactly the opposite of what you'd expect to see if it was the flu vaccine itself reducing mortality. The more likely explanation is that individuals who choose to innoculate are systematically different (healthier, less frail, better access to health care, better nutrition, less likely to be risk takers, or all of the above) in unmeasured ways than those who don't innoculate, and that is what has been behind earlier results showing lower mortality among the innoculated.

I agree that there's a tension between trying to rely solely on evidence-based medicine and needing to treat people now, when they are sick. However, (1) that's a very different argument than the one that is being made about the necessity of flu shots (which tends to run along the lines of "well SCIENCE proves this works, duh") and (2) in my mind raises the question of how long, exactly, it's ethical to continue providing medical treatment that you think (but are not sure) works. One year? Five years? Forever? If it's not ethical to do double-blind studies on the effectiveness of the flu vaccine in preventing excess deaths, then will it ever be? Or do we need to keep relying on faith or unproven belief forever? That's not a terribly satisfying outcome.
posted by iminurmefi at 1:01 PM on October 14, 2009


Ech, and reading the above, let me clarify: when I say "whether the vaccine works," I'm not disputing that its efficacy in lowering the risk of catching the flu among the innoculated. I'm talking about the narrower question of whether it is effective in specifically lowering the mortality rate due to flu, which seems to be the main question in the Atlantic article.

Like I said before, I've already gotten my seasonal flu shot and I'm planning on getting the H1N1 shot as well, because I'm young enough to be pretty confident that those shots will provoke an immune response in me and I have NO desire to get the flu.
posted by iminurmefi at 1:05 PM on October 14, 2009


This is the vilest use of hyperbole ever uttered in the history of human communication.

Well, without hyperbole we'd all be dead.
posted by flaterik at 1:08 PM on October 14, 2009 [2 favorites]


The Atlantic article cited only one paper that used carefully collected evidence in a population to address the effectiveness of the vaccine to reduce mortality (not the only measure of effectiveness, it is important to note). I found it helpful to actually read that paper(pdf). Note that not only is the dear departed MJ an author (I keed), but the senior author is Noel Weiss, a highly respected epidemiologist. And although the impact factor of IJE is nowhere near that of JAMA, it publishes high quality research, as its peer review process is quite rigorous (okay, I review for them occasionally; take that for what it's worth). This paper does not demonstrate that vaccination has no effect on mortality. Rather, it does show that there is a systematic bias toward lower mortality rates among vaccine users when compared to non-users. This is not a surprise; just about every study of people that show up someplace vs. those that don't show lower mortality in those that show up. It stands to reason. People enlisting in or drafted into the military have lower death rates than those who don't; workers are healthier than those not working; volunteers for prevention studies die more slowly than those who don't; people who come to the clinic to get screened or vaccinated live longer than those who don't. When you're in the process of dying, an often prolonged experience, you don't enlist in the Air Force or apply for a new job.

Both this bias and a true mortality effect can coexist comfortably, a possibility the paper does not attempt to address directly, because it can't. As the authors point out, even if the vaccine is very effective, the impact on all-cause mortality would be small, by necessity less than 10%. So the conclusion from that study may be that vaccine effectiveness in reducing all-cause mortality is not proven, but that is far from showing there is no effect. The authors themselves say in their discussion:
For this reason, our finding that differences in health status between vaccinated and unvaccinated groups leads to bias in estimates of influenza vaccine effectiveness against all cause mortality and other non-specific outcomes does not mean that there is no effect of vaccination against serious complications of influenza infection.
posted by Mental Wimp at 1:08 PM on October 14, 2009 [4 favorites]


the lower risk of death among the immunized population holds steady even outside of flu season--in fact, the risk of death diverges even further outside of flu season for the immunized--

Well, that's not quite a complete description. The differences between the groups diminishes following influenza season, such that a difference of 61% before the season becomes a difference of 44% during the season and a difference of only 26% after the season. But your point is that the difference persists, not that it is steady, so, okay.
posted by Mental Wimp at 1:19 PM on October 14, 2009


Doesn't even look like the author cited the right paper. I think she wanted this one, from the Lancet last year, by the same authors (Jackson, Weiss, etc.) It seems to say more about whether the vaccine is efficacious among the elderly.

Heh. Small world. Weiss and Jackson are part of the same school of public health that employs me. I've met Noel, but not Lisa.
posted by dw at 1:23 PM on October 14, 2009


Doesn't even look like the author cited the right paper. I think she wanted this one, from the Lancet last year, by the same authors (Jackson, Weiss, etc.)

But since The Lancet is one of the most prestigious medical journals, noting this wouldn't help the Atlantic authors' contention that this research is outright ignored by those nasty biased mainstream scientists who won't let you sit at the cool kids table at lunch if you publish the "wrong" conclusions.
posted by grouse at 1:33 PM on October 14, 2009


The fact that the difference in all-cause mortality was greater before the flu season in the innoculated than during the flu season is pretty strong evidence that the flu vaccine is not responsible for the observed difference, yes? Put another way: if you took two groups of individuals, one healthier than the other, and tracked all-cause mortality with no interventions, you'd expect to see exactly this pattern, wouldn't you, as the sickest in the unhealthy group die off quickly and the survival rates slowly improve for the unhealthy group?

I take your point, Mental Wimp, that the study doesn't definitely show that the vaccine has no effect. I know it's a sin in statistics to assume that not proving something is the same as proving something doesn't exist. For all of that, though, that line really read to me as more of a (not exactly boilerplate) "we acknowledge the limitations of our study" rather than something one should really point to as evidence that flu vaccines do or might actually lower death rates. It's kind of like saying "We can't prove there's no God" is some sort of evidence that God actually exists. If only we could get a powerful enough test for the presence of God, we could settle the question once and for all!
posted by iminurmefi at 1:34 PM on October 14, 2009


Hey, thanks for the reminder! After I spotted this story on the main page, I took my lunch break early and went to get my vaccination. I return $30 poorer, but richer in spirit and immunity.

As a fervently pro-science atheist, getting a flu shot is the closest thing I have to taking Communion.
posted by ErikaB at 1:45 PM on October 14, 2009 [3 favorites]


Hey, look! Pertussis is coming back to America! Thanks a lot, assholes.

Pertussis vaccine does not confer life-long immunity.

In other words, there's more to the resurgence of pertussis than just wingnuts not vaccinating their kids. How many people here have had a recent pertussis booster?
posted by oneirodynia at 1:46 PM on October 14, 2009


"we acknowledge the limitations of our study"

I don't think their disclaimer is just scientific modesty. They really do recognize that a difference exactly the size one would expect from the vaccine is hidden in there somewhere. For instance, they suggest a true mortality reduction effect could be in the range of 6%. Since we don't know the actual size of the bias and it could be (most definitely is, in fact) time-dependent, it could be that the 6% is a layer of that observed 44% difference. That would depend upon how quickly the 61% pre-season difference decays to the 26% post-season difference: is it linear, negative-exponential, Gompertz...? Given the absence of the counterfactual (i.e., there is no vaccine-group that didn't get the vaccine in this study), it is impossible to determine this from their study. It may be that's why some skeptics are proposing a randomized trial. That only makes sense if the only purpose is to reduce mortality, because reductions in incidence of influenza has already been examined in a randomized trial of the elderly.
posted by Mental Wimp at 1:48 PM on October 14, 2009


Sorry: They really do recognize that a difference exactly the size one would expect from the vaccine is could be hidden in there somewhere.
posted by Mental Wimp at 1:52 PM on October 14, 2009


I don't think their disclaimer is just scientific modesty. They really do recognize that a difference exactly the size one would expect from the vaccine is hidden in there somewhere.

Is hidden or could be hidden? I'm not denying the second is possible, I'm just having problems with the first--that conclusion doesn't seem to be supported by the actual findings. To my read, it seems like that paper pretty much leaves the question open as to whether the seasonal flu vaccine prevents any deaths, by showing that the previous evidence didn't actually support what those researchers thought it supported. Without further data--preferably from randomized trials--it seems like you can't say that the flu vaccine prevents deaths. (You can't say it doesn't, but I don't personally believe that medical care should be based on unproven beliefs.) However you've obviously read a lot more of this literature than I have and probably have a better read on caveats, and hell the entire method, than I do.

My background is on the policy side of health care financing and health delivery, so I admit my bias is to believe findings that show that there is a lot of health care delivered to marginal or no effect, just because that's the literature I'm most familiar with. Also, I get somewhat annoyed by the apparent hypocracy of people who scoff at religious beliefs or alternative medicine [neither of which I personally believe in] but can't be bothered to examine and re-evaluate their own beliefs when the received wisdom they hold about SCIENCE! is challenged. Seems to be some of that going on in this thread.

On preview: dammit, MW, you beat me! Well, I'm not going to delete this comment, but I figured you meant "could be."
posted by iminurmefi at 2:12 PM on October 14, 2009



Pertussis vaccine does not confer life-long immunity.

In other words, there's more to the resurgence of pertussis than just wingnuts not vaccinating their kids. How many people here have had a recent pertussis booster?


It used to not matter that it didn't confer life-long immunity, because it spreads much better among children (close quarters and coughing on each other) and they were all vaccinated, and pertussis was virtually eliminated in the US. But now, with the non-vaccinating wingnuts, it's spreading more among all of us. A simple solution has been found: tetanus shots now contain pertussis vaccine (as well as diptheria which has been in there for awhile).

I had a tetanus shot last month (we're all supposed to get them every 10 years) and so, yes, I have had a recent pertussis booster.
posted by hydropsyche at 2:18 PM on October 14, 2009


Since I now realize I managed to be thoroughly unclear, kids have been getting DPT (diptheria, pertussis, tetanus) shots for years. Since 2005, adults can now get what's being called Tdap which is a different formulation.
posted by hydropsyche at 2:21 PM on October 14, 2009


Y'know, this may be a boneheaded question, but wouldn't the efficacy of the vaccine be best measured through morbidity, not mortality?
posted by dilettante at 2:24 PM on October 14, 2009


My background is on the policy side of health care financing and health delivery, so I admit my bias is to believe findings that show that there is a lot of health care delivered to marginal or no effect, just because that's the literature I'm most familiar with. Also, I get somewhat annoyed by the apparent hypocracy of people who scoff at religious beliefs or alternative medicine

Oh, I couldn't agree with you more. My rough estimate is that 50% of what we spend is for ineffective care or worse. Some of our biggest ticket items may be doing more harm than good, and should be evaluated by randomized controlled trials. A few: solid organ transplants, CABG, PTCA & stents, prostate screening & surgeries, etc., etc., etc. My attitude is that all medicine is alternative; you gotta prove it works.
posted by Mental Wimp at 2:27 PM on October 14, 2009


How many people here have had a recent pertussis booster?

I also got one with a tetanus shot at the beginning of summer, all I know is that the vaccine must be made of cement or something because I felt that shot for months afterward.

But it was worth it so that I could resume my hobby of rolling around naked in shards of filthy rusted metal.
posted by quin at 2:31 PM on October 14, 2009 [1 favorite]


It used to not matter that it didn't confer life-long immunity, because it spreads much better among children (close quarters and coughing on each other) and they were all vaccinated, and pertussis was virtually eliminated in the US.

The resurgence in Canada of pertussis after 1990 was among previously vaccinated, school-aged children, teenagers, and adults:

"Pertussis affected predominantly children who were immunized with a vaccine introduced in the mid-1980s. The evolution of the age distribution of cases paralleled the aging of this cohort with a slow but steady drift of disease from early childhood to adolescence. CONCLUSION: The sudden increase in pertussis incidence in Canada can be largely attributed to a cohort effect resulting from a poorly protective pertussis vaccine used between 1985 and 1998."

I'm not saying wingnuts don't have an effect on vaccination patterns and subsequent epidemics- witness pertussis epidemics in Britain in the 70's after the widespread media backlash against the vaccine. I am saying that as much as people like to rant against anti-vaccinism, there's more to the specific example of pertussis resurgence than freaky anti-medicine folks.
posted by oneirodynia at 2:45 PM on October 14, 2009


Ugh, sorry, forgot to link to that quoted par.
posted by oneirodynia at 2:46 PM on October 14, 2009


I would have thought, with all the dismissive comments in response to this post, that the main article was extremely biased, badly written, or full of bad science and poor reasoning. It was not.
posted by millions at 2:57 PM on October 14, 2009


But since The Lancet is one of the most prestigious medical journals

It's one of them furriner journals from a country where they talk funny, so it's not prestigious at all. [Beck G, O'Reilly BO, et. al., J American Freedom Heroes, 2009 Sep 12, 15(20):974-79, with special color poster foldout]
posted by dw at 3:10 PM on October 14, 2009


(1) that's a very different argument than the one that is being made about the necessity of flu shots (which tends to run along the lines of "well SCIENCE proves this works, duh")

No, in this case it's more this is the best available solution we have that will work and causes the least amount of hardship on potential vectors and doesn't rely on those vectors being rigorous in performing tasks they may not be very rigorous at.

That is, going into every flu pandemic we have three available choices: social isolation, hygiene, and vaccine. Social isolation is extremely effective, but the economic costs are great. Hygiene is extremely effective, but then you're at the mercy of individuals not only being rigorous but learning how to be rigorous and remembering to be rigorous. And that, sadly, is a lot to ask for. So that leaves the vaccine.

(2) in my mind raises the question of how long, exactly, it's ethical to continue providing medical treatment that you think (but are not sure) works. One year? Five years? Forever? If it's not ethical to do double-blind studies on the effectiveness of the flu vaccine in preventing excess deaths, then will it ever be?

Seriously, welcome to obstetrics. There has been little research in the field, and even that research is often ignored. Given the declining birth rate, you're playing with fire if you're running double-blind trials on newborns and fetuses. I think you're running into the same thing here.

I'm not saying a randomized trial is unthinkable. But I do think that if you do it in a pandemic year like this one you're not serving science all that well.

I know where you're coming from with health policy, and I agree with you on unnecessary costs. But we know these vaccines work, and even with the Jackson et. al. study where the issue is more that in one group of people it may not be effective, there's no evidence that it's not working in healthier populations. So maybe vaccinating Grandma is a bad idea, but maybe vaccinating Junior is if he's around Grandma a lot.
posted by dw at 3:28 PM on October 14, 2009


I would have thought..full of bad science and poor reasoning. It was not.

Their critique of cohort studies indirectly raises the question of a double blinded study with random enrollment and so on. So far so good, except, the flu vaccine is typically based on what's going around in Asia in the spring, so you'd have to do your study in real time. And you're going to need a huge population to work on since you can really only expect a small portion of your experimental groups to contract the flu. And....

It's possible to create an experimental design that would satisfy their issues with the cohort studies they describe, but somewhere in there you're bound to cross a line such that the only people willing to run your testing protocol are the folks at Joseph Mengele Memorial Hospital.

I'm going to say that's a weak spot in their reasoning right there.
posted by Kid Charlemagne at 4:23 PM on October 14, 2009


This kind of crap is the last thing we need during a pandemic.

I'm tempted to make a cynical comment about the usefulness of weeding out those with poor reasoning skills, but it's just too depressing.
posted by BrotherCaine at 4:44 PM on October 14, 2009


dw, I agree that it's a really thorny issue about double-blinded RCTs in obstetrics, and to a lesser extent for potentially life-saving treatments for things like flu vaccines. I think I'm just pretty unsatisfied with the response that since it is ethically tricky, and the moral calculus isn't straightforward, we're gonna stick with just hoping that the interventions we have some evidence of are working well enough. That's all well and good if it turns out later that the intervention was in fact a net benefit; it becomes tragic when it turns out not to be and everyone asks, why the hell did no one test this until now? Why were we subjecting pregnant women or the frail elderly to some treatment that actually hurt them?

See: hormone replacement therapy. Or one of the many excellent examples that Shannon Brownlee provides in her book, particularly in regards to treatments for breast cancer--where again, the rationale for why we couldn't possibly do double-blind studies was that to deny someone this potentially life-saving treatment was on its face unethical. Except it turns out that oops, the treatment actually resulted in higher mortality, and countless women were exposed to it for no good reason--a far greater moral harm, in my opinion.

I do think that if you do it in a pandemic year like this one you're not serving science all that well.

Yeah, I got no argument with you there. I just bristle at the (usually implicit) idea that outcomes research or comparative effectiveness research should be taboo lest we discourage the latest public health campaign (e.g., we can't call into question the effectiveness of mammograms or prostate screening, because then people might defer preventative care! ARGH), but I agree that a pandemic year probably ain't the best time to do it for the flu.
posted by iminurmefi at 7:13 PM on October 14, 2009 [1 favorite]


The most disturbing thing I read in the article was this:
Influenza causes only a small minority of all deaths in the U.S., even among senior citizens, and even after adding in the deaths to which flu might have contributed indirectly. When researchers from the National Institute of Allergy and Infectious Diseases included all deaths from illnesses that flu aggravates, like lung disease or chronic heart failure, they found that flu accounts for, at most, 10 percent of winter deaths among the elderly

She seems to consider that a disease that causes 10 percent of winter deaths of the elderly per year (and hundreds of thousands of total deaths a year) a small thing.
She uses hyperbole when discussing the vaccine, and reverse hyperbole when discussing the deaths (only a small minority of deaths).

Sheesh!

The one good point, that is already well known, is that the vaccine doesn't seem to have much affect on the elderly. But as many people here have mentioned, when younger people get the vaccine, they are protecting the elderly by not getting sick. If I'm not sick when I visit my parents, they are much less likely to get sick.

And her whole point about the vaccines where they guessed wrong about which flu was being spread and how deaths didn't decrease misses the mark because even flu shots that don't get it right still provide some protection. In fact the 1976 swine flu vaccine that was considered a colossal failure, seems to be reducing the deaths from the present H1N1 flue virus among the now-elderly who received that vaccine (deaths are lower among the elderly getting H1N1 than among the young).
posted by eye of newt at 10:36 PM on October 14, 2009


And a note about flumist:

They take a mild type-A flu virus (called A/Ann Arbor/6/60), 'attenuate' and 'cold adapt' it somehow so it it doesn't cause flu symptoms in most people and can only survive in your outer nose or throat, then through some type of recombinant bioengineering, put harmless pieces of the more dangerous flu on the outside of the 'safe' flu, then put it up your nose.

The result is like a small kid with a halloween mask--your immune system thinks it's the scary flu and creates antibodies against it.

About 1 in 18 react to the mild type A flu with flu-like symptoms. In other words, flumist gives you the flu. It is only in your nose and throat (pain, fever, but no coughing or throwing up), but it is unpleasant nevertheless. I know this, as you may have guessed by now, not because I'm a medical expert, but because I received flumist vaccination many years ago and proceeded to get the 'flumist flu'. I hope they have better attenuated it since then.
posted by eye of newt at 11:01 PM on October 14, 2009


The only time I ever got the flu was the winter before I came down with a little more debilitating illness called cancer. The cancer was debilitating pain. The flu was debilitating illness. When both were managed, the cancer was much more bearable. With the flu I seriously felt like I was dying.

I am not an idiot. I understand the cancer was killing me and the flu was not, but the symptoms of the flu were the worst I have ever experienced. I could not get out of bed. I would vomit after drinking water. Granted, with the cancer I had plenty of nice nurses looking after me and adjusting my fluids and bringing me pre-arranced sammiches. Fortunately I had the common sense to develop cancer in California and the medicinal marijuana handled almost all of the side effects of the chemo.

The flu is bad. For those who are healthy, I can see it's just an annoyance. But if you are fighting something else ... I can see it killing you. I have a really hard time making this argument with my friends but it's a bad thing, and if you are weak, it can end you.

My ma keeps bugging me about getting each new years vaccine. I've got reasonably good hygiene, and I'm now healthy. I have a hard time justifying why I should get this vaccine if there is at all a chance those who might need it don't get it. Sorry mom, I'm fine ...
posted by chemoboy at 12:14 AM on October 15, 2009


""Oh, I'm dividing! Am I getting the right growth signals from the rest of the body to confirm that it wants me to divide? Is my DNA completely intact? Do I have enough resources to pull this off without causing damage?" and so on. If any of the answers are no, the cell commits suicide."

There's an excellent movie called Death By Design that's all about this. I found it accidentally while taking out movies from the library. It had all sorts of cool computer graphics and no description on the box; I thought it was a horror movie. Nope, just science about cells!

"You cannot, and ethically speaking should not, force, coerce, or encourage people to undergo medical procedures that benefit society when the risk of the procedure is bourne by the patient alone."

Bullshit. The only way to support this line of reasoning is an insane individualist philosophy, which could fairly be called sociopathic.
posted by klangklangston at 10:10 AM on October 15, 2009


You cannot, and ethically speaking should not, force, coerce, or encourage people to undergo medical procedures that benefit society when the risk of the procedure is bourne by the patient alone.

Immunization is a lot less restrictive of individual liberties than quarantine.
posted by BrotherCaine at 10:32 AM on October 15, 2009 [1 favorite]


An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All
posted by homunculus at 8:06 PM on October 19, 2009 [1 favorite]


Over at Effect Measure, revere responds.
I keep getting asked about the Atlantic Magazine article, Does the Vaccine Matter? by Shannon Brownlee and Jeanne Lenzer, two reporters whose particular bias is that we as a nation are "over treated." As a generalization that's probably true, and finding examples isn't hard. Unfortunately by taking as their main example flu vaccine during a pandemic, they have not only picked the wrong example but created more confusion at a time when there's already too much. ...

The maddening thing about this article is that there are valid points to be made here and we have tried to make them until we were blue in the face (random examples here, here, here, here, here, here). We have always felt the way to prepare for and battle a pandemic is to rely on a strengthened and robust public health and social services infrastructure, not to plan for the best (that there will be an effective and timely vaccine available to everyone) while hoping the worst won't happen. Vaccines and antivirals are a poor second best as a strategy. But that's what we have now, and while not the optimum, they do work. On the other hand, the nostrums also touted in this article as a substitute for vaccines and antivirals, like washing your hands, have almost no scientific support in the literature for influenza. They are still good things to do, although if Dr. Jefferson decides to review the literature, I wouldn't count on him finding any support for them. So what?

The bottom line is this. There is excellent and credible evidence in the scientific literature that vaccination against influenza reduces infections in people under 60, evidence that even Dr. Jefferson accepts. For those over 60, there are legitimate questions that were raised by others about the extent of the benefit of seasonal flu vaccine, but they were raised before Jefferson got into the act. The argument put forward in this piece is a straw man argument as far as pandemic influenza is concerned (and in which context it was placed).

I understand the rhetorical value of having a martyr-hero when pitching a story, but this was a particularly irresponsible time to pull this stunt.
posted by maudlin at 8:53 AM on October 24, 2009


The always great Dr. Mark Crislip just ripped this article to pieces in an "annotated" version posted over on Science-Based Medicine. Check it out here.
posted by inoculatedcities at 10:15 AM on November 8, 2009 [1 favorite]


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