Tag Archives: vaccines

Polio vs. bin Laden

Like most Americans, I felt a visceral surge of patriotic pride when I heard that we’d killed Osama bin Laden: pride in the President who ordered and orchestrated the bold raid, pride in the military that carried it out, and pride in a nation that, after nearly a decade of half-measures and absurd distractions, finally hit the primary target in the battle against Al Qaeda. We got the sonofabitch. I loathe violence and oppose capital punishment, but I’m pragmatic enough to understand that in some very, very rare cases, the only correct solution is a bullet. This was one of those cases.

But we have to be wary of surges of patriotism. They come from a place beyond reason, a primitive part of our tribal psyches, and leaders of all sorts have exploited them ruthlessly throughout history. As soon as the initial cheering dies down, we must set aside the easy jingoism and force ourselves to ask some hard questions. Exactly what did we just do, what did it cost, and was it really, objectively worth it? While asking those questions, though, we have to appreciate the conditions under which the decisions were made.

Fortunately, more than a year after that fateful night in Abbottabad, this phase of post-game analysis is still in full swing. Many foreign policy wonks bemoan the precedent the raid set: landing troops inside a sovereign nation without permission to carry out what can only be described as an assassination. US relations with Pakistan were fragile before; the two nations are barely speaking now.

Public health and infectious disease geeks like me, meanwhile, have been wringing our hands over a Central Intelligence Agency operation that took place before the raid. At the time, the Agency had a major problem. They’d pinpointed a residential compound where they strongly suspected bin Laden was holed up, but they couldn’t be sure. The man they saw pacing the courtyard in reconnaissance photos could have been him, or could have been some wealthy hermit with no connection to terrorism. When you’re on the cusp of dropping dozens of Navy SEALs into someone’s yard in the middle of the night and triggering an international incident, you really want to be sure you have the address right. The spooks decided to get creative.

Enlisting a Pakistani doctor named Shakil Afridi, the CIA mounted a campaign to collect DNA samples from children in Abbottabad, under the cover of a hepatitis B vaccination program. Afridi deployed nurses first in the slums of the city, then moved the campaign closer to the suspected bin Laden residence. If children from the target house carried bin Laden DNA, it would mean that Osama was most likely there. The effort appears to have failed, but the President ultimately took an enormous risk and authorized the raid anyway.

The public health community has been fiercely critical of this “fake” CIA vaccination campaign ever since. This recent post from infectious disease blogger Maryn McKenna typifies the general sentiment, which was exactly how I felt when I first heard about this incident. Laurie Garrett, meanwhile, took a more sensationalist tone in a shrill (and inaccurate) rant last month.

Other than a snide remark on Twitter when the news first broke, I’ve kept pretty quiet about this story. That’s because when I learned more details of the operation and started analyzing it, I became – and remain – deeply conflicted about it.

Public health has always been the poor cousin of medicine. When it works perfectly, nothing happens. There’s no dramatic moment when the patient’s heart re-starts, no miraculous recovery as the antibiotics take effect, no made-for-TV journey from sickness into health. The gains from vaccination, sanitation, and prevention are enormous and real, but they accrue on statistical tables that are very hard to explain to non-specialists.

As a result, public health workers have spent decades earning the public’s trust, especially among the poor and marginalized populations that suffer disproportionately from preventable diseases. When the amply-funded CIA made the cynical decision to hijack that hard-won trust for a short-term military objective, people in the field were understandably upset. That said, the Agency’s decision was not entirely arbitrary, and its impact wasn’t necessarily as bad as some commentators have implied.

Let’s get some perspective here. This DNA-collection effort was part of a broader project to stop a prolific mass-murderer. Osama bin Laden did not have blood on his hands; he was swimming in it. This was a man who had directly masterminded the deaths of several thousand innocent civilians, triggered a war that killed and maimed tens of thousands, and continued to promote and design attacks to kill many thousands if not millions more. He made no secret of his desire to annihilate Israel, destroy Western civilization, and roll human rights back to the Middle Ages. The only meaningful distinction between bin Laden and Hitler was that the former did not control sufficient weaponry to scale up his plans – yet. Public trust in vaccination campaigns is certainly important, but it is not all-important. Other priorities do exist.

Nor was the CIA’s betrayal a unique affront to public health. Yes, there have been some setbacks in the World Health Organization’s vaccination campaigns in Pakistan since the bin Laden raid, but it’s not clear the CIA caused those problems. Indeed, the polio eradication campaign, originally slated to be done in the year 2000, has been struggling for years. Pakistan isn’t even the toughest challenge for WHO vaccinators at the moment – Nigeria is. The covert DNA screening surely didn’t help matters, but it’s ridiculous to presume, as Garrett apparently does, that everything in public health would be going perfectly if the CIA hadn’t done this.

Finally, while it certainly wasn’t a very well-structured vaccination campaign, and it was clearly done with ulterior motives, it’s probably not correct to refer to the CIA effort as “fake.” As far as we can tell, the Agency obtained and distributed real hepatitis B vaccine. I presume they chose an injected vaccine because it provided better cover for DNA collection than the oral polio vaccine. A proper hepatitis B immunization requires three doses spread out over six months, but partial immunization still provides some protection against the virus. A handful of Pakistani kids may avoid liver cancer because of this. That’s not a justification, just an observation.

So was the hunt for bin Laden ultimately worth the cost? I still don’t know. I do know that it’s neither fair nor useful to judge the entire operation through a single narrow lens, with information that was only available after the fact. The DNA collection may have failed, but nobody knew it would fail at the outset. The President authorized the raid anyway, but given how thin the evidence was, it would have been perfectly reasonable for him to call it off, leaving the world’s top terrorist alive to plot his next attack.

Foreign policy is full of the nuances, tradeoffs, and uncertainties of a deeply imperfect world. We can and should hold our government to account for its actions, and we can and should point out the real harms that come from undermining public health efforts. But a decision can only be bad if another option was clearly better, and in this case I can’t quite bring myself to condemn the CIA’s choice.

Just don’t make a habit of it, okay guys?

So Does The Flu Vaccine Work Or Not?

A paper that came out Wednesday on influenza vaccine efficacy has generated a new round of speculation about what is probably the hardest sell in the vaccine business. There’s a lot to complain about with our current flu vaccines: everyone needs a new shot every year, vaccine makers don’t always guess right about which strains of flu will be circulating that season, and plenty of people can tell stories about how they got the shot and still got sick.

Now, in the middle of flu vaccine season, we get a new peer-reviewed report – and of course an accompanying press release – that seems to bring more bad news:

“Evidence for consistent high-level protection is elusive for the present generation of vaccines, especially in individuals at risk of medical complications or those aged 65 years or older. The ongoing health burden caused by seasonal influenza and the potential global effect of a severe pandemic suggests an urgent need for a new generation of more highly effective and cross-protective vaccines that can be manufactured rapidly”, explains Michael Osterholm from the University of Minnesota, USA, lead author of the study.

The news coverage was a mixed bag, ranging from predictable rantings from the antivaccination nuts (no links – you can find them yourself) to balanced, nuanced explanations such as this. Most of it was somewhere in between, no doubt confusing plenty of regular folks.

While Mark Crislip provided a typically excellent and thorough overview of flu vaccine efficacy back in ’09, I’m just going to highlight a few important features of the new paper from Osterholm’s group.

First, there’s not really any news here. Yes, Osterholm and his colleagues did yeoman’s work mining the literature and compiling their data, but they could not escape the fundamental limitations of all meta-analyses. In a meta-analysis, researchers look at existing publications, pick the ones that meet a particular (and in this case extremely strict) set of criteria, and compile the results into a new paper. There’s no new experimentation involved.

Furthermore, the conclusion of this particular meta-analysis should surprise exactly nobody. We’ve known for a long time that flu vaccines are imperfect, and while Osterholm has now put specific numbers on that imperfection for particular age groups, those numbers are neither definitive nor shocking.

Osterholm’s latest results weren’t exactly secret, either. He presented them at the National Influenza Vaccine Summit in May, and the conference report I wrote for them went on the NIVS web site this summer. It may not be in the top of everyone’s news feed, but anyone who’s really tracked this issue closely already knew these results were coming.

These findings don’t alter the main conclusion of decades of public health advice, either. Flu vaccines aren’t 100% effective, but given their outstanding safety record, and the very real risks involved in catching the flu, they’re a whole lot better than nothing.

Finally, while the study’s headline conclusion was that vaccine efficacy averages only around 59% in healthy adults, the team also found that the H1N1 pandemic flu vaccine was a bit above average (69% effective), and discovered even better results for the live attenuated flu vaccine (LAIV, also known as FluMist) in one of the groups at highest risk of severe flu infection:

By contrast, LAIV showed significant protection against infection in young children, preventing influenza in 83% of children aged 7 years or younger. However, the Advisory Committee on Immunization Practices (ACIP) does not currently recommend LAIV over TIV in these children.

Besides its apparently higher efficacy, FluMist has another huge advantage: it’s inhaled rather than injected. My daughter used to scream her head off each Fall before, during, and after her flu shot. Now she can barely stop giggling through the procedure. With the new meta-analysis showing that this snorted vaccine is probably more effective for her than the shot, I can feel good about it as both a virologist and a father.

Elsevier Makes Good: Original Wakefield Takedown Now Free

Awhile back, I blogged about a particularly insidious glitch in the biomedical literature, in which a fraudulent study that caused enormous harm was available for free, while a contemporary – and strikingly prescient – commentary that eviscerated that study was locked behind a paywall. Now, thanks largely to the perserverance of TWiV co-host Rich Condit, this situation has been fixed.

Rich followed up on his original request, pulling strings with several contacts he’d made at Elsevier. He forwarded the conclusion of the saga this morning:

Dear Professor Condit

On behalf of Dr Astrid James, I can confirm that both the commentary and article in question are now free to access, subject to (free) registration on www.thelancet.com

Many thanks.
Richard Lane
Web Editor
The Lancet

Now, not only can the general public read the infamous and now retracted paper from Andrew Wakefield, which purported to show a link between MMR vaccination and autism, but also the brief, thorough debunking of that paper by Robert Chen and Frank DeStefano. Thank you Rich, and thanks to the folks at Elsevier who finally got the point.

The only remaining question is why, in light of Chen and DeStefano’s analysis, The Lancet even published Wakefield’s paper in the first place.

Our Cross to Bear

I’m an atheist, but for social reasons I occasionally have to sit through a church service. This past Easter, I did it again, and found the sermon particularly interesting, though not in the way the pastor intended. Visiting a common theme, she talked about how preposterous Easter is: the idea of someone rising from the dead, the shortage of witnesses to the event, and the questionable credibility of the few who did supposedly see it. The lesson was supposed to be that only someone of great faith would believe such a story, thus proving that Christians are the most pious people.

Instead of a religious epiphany, though, I had an anthropological one. Believing in something absurd is a good way to be ridiculed – and that’s exactly the point. By professing their beliefs, the faithful are not really trying to convince outsiders of anything. The entire purpose is to incur derision, so that they can point to it as proof of their faith.

Crosses. Courtesy Flickr user istolethetv.

This is the whole point, apparently.

“Look at what I endured for our beliefs,” they want to say. It cements their position in the community of their faith, and also challenges others in that community to outdo them. Someone else then professes the absurd beliefs to an even larger crowd, incurring even more ridicule, and earning even more esteem among the faithful. If they make enough of a nuisance of themselves to get arrested, injured, or killed, they’ll be made into saints.

Arguing with these faith-based absurdities is not only unproductive, it’s actively counterproductive. Believers want to hear someone elaborate all the ways their beliefs are wrong. They thrive on the rational disproofs of their position. They crave the scorn.

As interesting as that insight was, I didn’t think it applied to anything beyond traditional organized religion. This week, I suddenly realized that an entirely new kind of religion has quietly sprouted over the past few years, and that its tendrils now extend into a wide range of scientific topics. I don’t have a name for these new religions yet – maybe Forum Faiths, or E-tribes, or Chatroom Counterfactuals would work. Regardless of the terminology, the pattern is always the same.

Start with a controversial but completely testable statement – a hypothesis. This frames the discussion as a scientific one, even though you have no intention of pursuing it scientifically. Say that vaccines cause autism, or that a newly discovered retrovirus causes chronic fatigue syndrome, or that people with delusional parasitosis are actually infected with real parasites. The specifics don’t matter, all that matters is that you pick a topic someone will care about, and make a surprising claim that some people will want to believe.

Now present a tiny shred of data supporting the hypothesis, but tell everyone that you’re sure it’s going to turn out to be true. This establishes the faith. True believers will immediately sort themselves out from the crowd, latching onto the hypothesis and proclaiming it as fact, even though (or perhaps especially because) the data are so scanty.

From that point forward, every new piece of evidence against the hypothesis will only reinforce the faith. Some of the early adopters, who were misled by thinking this was an actual scientific exercise, will abandon the group once the new data come along. The true believers, though, will become more adamant. They’ll meet in online forums every time a new refutation comes along, so they can agree on talking points to answer it. They will then spam every blog, forum, and news site with comments that appear to be arguments, but which are actually protestations of their faith.

As unbelievers respond to those comments, the believers will persist until their arguments are completely absurd. Then they’ll be ridiculed for their irrationality, at which point they’ve won. They can return to their groups and point to the suffering they’ve felt for the faith. Their esteem among the faithful will rise, even as the rest of the world considers them idiots.

Meanwhile, the charismatic leader of the faith – The One who originally presented the shred of data – will follow the same pattern but in the professional world. He or she will argue with the scientists whose data don’t support the hypothesis, until the arguments become absurd. The scientific community will then marginalize and ignore The One, because they don’t have time to deal with willful idiocy. Of course, to the faithful this only proves that The One is a true martyr, and that the unbelievers are conspiring against them.

I don’t have a solution to this. Ignoring these counterfactual religions won’t work, particularly when they make claims that can profoundly affect public health, and arguing with them obviously isn’t going to help either. Science is ultimately self-correcting, so poorly-controlled, fraudulent, or simply erroneous results will eventually be expunged and most of the world will move on. The true believers, isolated in their little cul-de-sacs of falsehood, may gradually dwindle over time. All that will be left will be the damage: kids maimed and killed by vaccine-preventable diseases, sick patients made sicker from drugs that never could have helped them, families destroyed by untreated psychoses.

As religious casualties go, I suppose it could be worse. But in the twenty-first century, I wish we could do better.

Vaccines and Autism: The Bullshit Continues

A news item a few days ago has fired up a new round of the old “vaccines cause autism” nonsense. The story correctly states that the National Vaccine Injury Compensation Program has awarded a substantial amount of money to the family of a girl who appears to have been injured by a vaccine. And that’s about the only thing in the story that’s correct.

Continue reading

Not What I Expected, Either

I see anywhere from dozens to hundreds of scientific news releases and stories each day. Even if it weren’t my job to keep up on these developments, I’d probably still be addicted to reading them, because once in a great while one of them puts my jaw on the floor. Today it happened again:

An experimental vaccine prevented HIV infections for the first time, a breakthrough that eluded scientists for a quarter century.

A U.S.-funded study involving more than 16,000 volunteers in Thailand found that a combination of ALVAC, made by Paris- based Sanofi-Aventis SA, and AIDSVAX, from VaxGen Inc., of South San Francisco, cut infections by 31.2 percent in the people who received it compared with those on a placebo, scientists said today in Bangkok. Neither vaccine had stopped the virus that causes AIDS when tested separately in previous studies.

I think it’s fair to say that most virologists weren’t expecting this result. Or, as one HIV vaccine expert put it:

The latest result will transform future research, said Mitchell Warren, director of the New York-based AIDS Vaccine Advocacy Coalition.

“Wow,” said Warren, who was not involved in the study, in a telephone interview today. “We are in a new place in the search for an AIDS vaccine. It’s safe to say that the scientific community is caught off-guard.”

Now it’s time to start asking the interesting questions, like “why would two vaccines that didn’t work separately suddenly work when combined?” and “can we boost protection even higher by adding more components to this vaccine?”

via: Bloomberg.

WHO Finally Gets The Memo, but Leslie's Still Missing It

I’m a bit peeved with science journalist Leslie Roberts. She’s a fine writer, but as my graduate school mentor and current TWiV co-host Vince Racaniello has reminded me, she continues to screw up the story of polio eradication.

Vince has an excellent post on his blog today about the main story. In a nutshell, it seems that the World Health Organization (WHO), still struggling through an interminable campaign to wipe out polio, has had a shocking realization: they might need to consider switching to a different vaccine. To understand the sarcasm in the previous sentence, take five minutes to read Vince’s post, then come back here.

Okay, now that you’re back, let’s go to the Science news story that set me off. The full text requires a subscription, but this paragraph is the biggest problem:

The first big complication came in 1999 when scientists realized that the weakened virus used in the live oral polio vaccine (OPV) could revert to its neurovirulent form in rare cases and spark an epidemic. Thus was born the “OPV paradox”: OPV was necessary to eradicate the virus, but as long as OPV was in use, eradication could never be achieved. As a solution, World Health Organization (WHO) scientists proposed a plan: After the world was certified polio-free, all countries would stop using OPV simultaneously, as if at the stroke of midnight.

Actually, the scientific realization that OPV can throw off neurovirulent mutants came about thirty years earlier – it just took the WHO until 1999 to admit that this was a problem for their plan. Furthermore, the mutations don’t seem to be restricted to “rare cases.” There’s good evidence that OPV-vaccinated individuals routinely excrete virulent poliovirus in their stools.

Nor was this some obscure finding that had to be rediscovered from a dusty archive. In 1997, just two years before the big OPV-associated outbreak in the Dominican Republic that highlighted the issue, Vince and I warned of precisely that outcome, and argued that the WHO’s endgame strategy was absurd. Our paper, incidentally, was published in Science.

Roberts picked up the eradication story for the same journal in 2004, profiling the leaders of the WHO campaign in a long news piece and discussing some of the problems they were encountering. It was good reporting, but it ignored some critical history and fumbled some important facts, so I wrote a letter about it. I can certainly understand a reporter not trolling the archives for every prior publication on the issue, but I assumed she’d at least read the published letter correcting her, and not make the same errors in the future.

That obviously didn’t work, so here’s another shot at it. Maybe this blog post will turn up in Leslie Roberts’s next Google search for polio eradication. Leslie, if you have any questions after reading this, you can contact me through this site, or reach Vince (a genuine virologist who’s much more credible on this issue) through his blog.

Don’t Back Down, Amanda

In today’s New York Times, there’s an inspiring story about the long-delayed backlash against antivaccination zealots. Thanks to a courageous new book from pediatrician Paul Offit, rational thinkers are finally getting up the nerve to put these folks in their place:

In recent years, the debate over vaccines and autism, which began in fear and confusion, has hardened into anger. As Dr. Offit’s book details, numerous studies of thimerosal, measles virus and other alleged autism triggers in vaccines have been conducted, and hundreds of children with diagnoses of autism have undergone what he considers sham treatments and been “cured.” Both sides insist that the medical evidence backs them.

Those backing Dr. Offit say he was forced into the role. Opponents of vaccines have held rallies, appeared on talk shows like “Oprah” and “Imus in the Morning,” been the heroes of made-for-TV movies and found a celebrity spokeswoman in Jenny McCarthy, the actress and former Playboy model who has an autistic son. Meanwhile, the response from public health officials has been muted and couched in dull scientific jargon.

Amanda Peet

However, celebrity MILF Amanda Peet has now joined the fight on the side of science:

In an interview with Cookie, a magazine for parents, Ms. Peet called antivaccine parents “parasites” because they relied on other children’s immunity to protect their own. She later apologized for the word but emphasized that parents should get their medical advice from doctors, “not from me or any other celebrity.”

I have two messages for Amanda: 1) You’ve now replaced Angelina Jolie on my laminated list, and 2) don’t apologize – they are parasites.