A wrong way and a right way to discuss vaccine safety and effectiveness

Any resemblance to your child is completely intentional

Once again I’m blogging about vaccines, and antivaccinationism. Few health interventions that are both demonstrably effective and remarkably cost-effective seem to stir such opposition among a small but vocal few. I have noted before the remarkable statistic that vaccination has prevented more Canadian deaths in the past 50 years than any other health intervention.  Yet as long as there have been vaccines, there has been those that oppose them. I’ve spent quite a bit of time outlining the tactics and tropes of the antivaccine movement as well as considering ways in which health professionals and science advocates can improve the way they respond to antivaccinationism.

Rebutting anti-vaccine rhetoric is an unrelenting struggle, but an important one. As I’ve described in prior posts, viewing anti-vaccine material for only five to ten minutes increased the perception of risk of vaccination, and decreased the perception of risk of omitting vaccines, compared to viewing neutral websites. It also lowers vaccination intentions. By changing perceptions of safety, the willingness to vaccination decreases. One of the common themes in anti-vaccination content is raising questions about safety and effectiveness. It’s also the least obvious way to subtly sow concerns about vaccines.

A common way to embed anti-vaccination sentiment in messaging that professes to be science-based is to question the tactics and messaging of pro-vaccination, public health advocates. This is often termed “concern trolling” in online forums, and is common in discussions where there are significant ideological differences between the two groups. From WiseGeek:

Concern trolling is a form of Internet trolling in which someone enters a discussion with claims that he or she supports the view of the discussion, but has concerns. In fact, the concern troll is opposed to the view of the discussion, and he or she uses concern trolling to sow doubt and dissent in the community of commenters or posters. Although this practice originated on the Internet, it has since spread to the real world as well, with concern trolls popping up in a variety of places from network television to op-ed columns.

Artful concern trolling involves developing a believable persona as a supporter of a cause who has legitimate concerns. In an example of concern trolling, a group of people might be having a political discussion on a website about a candidate they support. The concern troll would log on and say “I’m concerned that this candidate might not be strong enough to beat the opposition,” or “I’m worried that the candidate’s history in the legislature might be a problem in the election.”

In the case of vaccines, the concern troll often uses the “Just asking questions” approach, posing questions about vaccine safety or effectiveness, that to the less familiar reader, seem superficially reasonable and legitimate. This is sometime called the “I’m not anti-vaccine, I’m pro-safe vaccine” trope. Once you understand the tactic, it’s easy to spot. Which brings me to the recent post by Alan Cassels on the Pharma Watch Canada blog. Entitled, “Time to outlaw vaccine propaganda: Are we taking the easy way out by labeling vaccine questioners anti-science loonies?” He asks,

Are lifesaving vaccines being ignored by parents because of illegitimate safety concerns?

That’s what many prominent health pundits think, including André Picard at the Globe and Mail. When commenting on an apparent rise of whooping cough, Picard wrote that the increase was the result of parents “shunning vaccination in small but significant numbers because of imaginary fears largely concocted by quacks and charlatans.”  Steven Salzberg, a blogger at Forbes Magazine echoed this sentiment pointing to celebrity doctors who “use their medical degrees and their faux concern ‘for the children’ to frighten parents into keeping their kids unvaccinated.” Salzberg also added that the “the media has been complicit in spreading some anti-vaccine misinformation.”

I’d agree that the media might be a problem, adding to the illegitimate vaccine fear floating around, and likely reducing parents’ willingness to immunize their children. And we certainly have our share of charlatans and quacks in cyberspace, aided and abetted by cyberchondriacs of all stripes.

Yet there is real fear among parents, a fear that is palpable. One survey of American parents a few years ago found that the majority of parents agreed that vaccines protect their children from disease but more than 50% expressed concerns regarding serious adverse effects. The same survey found more than 10% of parents had refused at least 1 recommended vaccine. What is at the heart of these concerns? Can it really be due to vaccine fear-mongering?

I don’t think it is. Parents just want to keep potentially harmful things away from their children.  And they turn to health experts for guidance, but here’s my take on things:  health authorities often fail to acknowledge the risks of some vaccines, refuse to discuss uncertainty over a vaccine’s effectiveness, hype the seriousness of common everyday viruses (c’mon folks, really? The flu? Chicken pox?) and keep piling more and more vaccines onto the list of ‘recommended’ childhood shots threatening to turn our kids into pincushions. Now you’ve got a recipe for even more skepticism and fear-mongering.

This is only the intro to the post so I encourage you to go and read it in its entirety.  Even in this short passage I can spot some common tropes used by antivaccinationists, such as minimizing the severity of the diseases, and stating that health authorities often don’t discuss vaccine risks (both of which are false). Plus there’s the inflammatory language of referring to children as “pincushions”, wording right out of antivaccine messaging. I could continue to point out the tropes, errors, and complaints in his list of what he terms “pro-vaccine hectoring” and “patronizing assurances” from public health advocates. But two bloggers have beaten me to it. Over at Skeptic North, Richelle McCullough has done a thorough line-by-line rebuttal to the entire post. And Orac at Respectful Insolence has also weighed in, with Antivaccine fear mongering? What antivaccine fear mongering? I don’t see any antivaccine fear mongering, which currently has received 283 comments, many of which point out additional problems and factual errors in Cassels’ post.

To be perfectly clear, not every post that looks like concern trolling actually is concern trolling. Someone that sounds like a concern troll, could be genuinely misinformed about the facts. I hope that is the case with Cassels, and that he doesn’t really think that the National Vaccine Information Center (NVIC), is a credible source of information. (It isn’t.) Cassels is a ” pharmaceutical policy researcher” and not a health professional or someone with any particular expertise in public health or immunization. So let’s hope we see some clarifying comments soon. As I have noted before, I had no idea about the tactics of antivaccinationists, and the extent of the anti-vaccine movement, until I began answering questions about the H1N1 influenza vaccine.

Let you think that I always equate criticism of vaccination programs with antivaccinationism, let me point you to another post that raises legitimate issues related to immunization without sounding like concern trolling. This post is from the Healthy Debate blog and is written by Ann Silversides & Terry Sullivan,  entitled, Promoting vaccine benefits: public health officials call for a rethink of communication with parents. Silversides and Sullivan identify and analyze several issues that are limiting uptake of vaccines:

Public health officials must find better ways to communicate with parents about the risks and benefits of childhood vaccination, researchers and public health officials agree. That task is particularly challenging in the absence of a national, or a provincial, vaccine surveillance registry because, to target messages effectively, accurate and timely information about vaccination rates and trends is critical. Primary health practitioners can also play a key role by engaging parents in non-judgmental discussions about vaccination at key moments during the course of having children and early development. The call for better information and better communication is prompted by the re-emergence of vaccine-preventable illnesses, such as whooping cough and measles, the outbreaks of which are associated with a drop in vaccination rates.

The issues they raise include:

  • There is no vaccine registry in Canada, meaning that there is no systematic tracking of vaccinations administered. This limits the ability to track trends more closely and target communication to parents more effectively.
  • There is an increased propensity for parents to seek non-medical exemptions from vaccination laws.
  • There is an increasing polarization of viewpoints on vaccination.
  • Public health messaging is essential, but inadequate to address parental concerns. Public health agencies are effectively not participating in social media.
  • The belief that a “healthy lifestyle” can protect against communicable diseases is prevalent, but wrong.

I like much of what they suggest, though I would have liked to see the authors  acknowledge that there is an anti-vaccine movement at work, and that anti-vaccine fears among parents are not developing out of thin air. Further, there are specific tactics and tropes used by the anti-vaccine movement – I’ve documented many of them. Understanding this is essential to spotting anti-vaccine sentiment and countering it effectively. Silversides and Sullivan are correct with their other points: It is absolutely true that public health agencies are largely absent on social media, where enormous amounts of antivaccine misinformation is spread. And they raise the hugely important issue of a Canadian vaccine registry. A few years ago I discussed a case control study on vaccines and autism and commented that the study couldn’t have been done in Canada – because the American managed care organization used an electronic medical record to track all vaccinations. That type of record-keeping just does not exist in an electronic form anywhere in Canada. On balance the post is a good one though, offering constructive criticism without one lapsing into “false balance” around safety and effectiveness, or making errors about the current state of public health messaging.

Vaccines are a remarkably safe and effective health intervention. Yet there are many factors contributing to a waning acceptance of immunization programs. Better strategies to address the contributors to lapsing confidence are required. To succeed, we must understand motivations. Parental concerns are a reality and must be addressed effectively by health professionals.  But it must also be kept in mind that many concerns are usually rooted and stoked by deliberate anti-vaccination campaigns that inflate risks, spread misinformation and ultimately aim to undermine confidence in immunization programs.

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8 thoughts on “A wrong way and a right way to discuss vaccine safety and effectiveness

  1. Yes, but some people are worried about vaccinations. And we are not 100% consistent. Some people agree with some vaccinations, not with others I am up to date on Tetanus, 3 times small pocks (do not know anybody else who has 3 of those). Never had a flu shot. Agree that there is a lot of fear mongering out there, but the internet gives us this wonderful ability to do a little research and decide. Just like I decide what I eat and drink…..not Bloomberg.

  2. Elke, the problem is that what you decide to eat and drink has no effect on other people. However, if you fail to vaccinate, it certainly does affect other people because now you risk transmitting diseases to others. The dramatic rise in whooping cough, which is deadly to infants who cannot be vaccinated until they reach a certain age, is a perfect example of how people not getting vaccinated ends up harming others.

  3. elke blinick:

    times small pocks (do not know anybody else who has 3 of those).

    Perhaps that has to do with your age. I received my seventh and last smallpox vaccination in 1974 because I was living overseas (I also got a typhoid vaccine that week). Both Canada and the USA stopped smallpox vaccination for the general population in 1972.

    I was given a Tdap last year, and the rest of my family has been caught up with it this summer. Which is important, since there seems to be a baby boom on our little street (three little baby boys, and another baby on the way when the new family moves in down the street).

  4. What do you think about this?

    http://www.reuters.com/article/2013/01/22/us-narcolepsy-vaccine-pandemrix-idUSBRE90L07H20130122

    People have legitimate concerns.

    The ‘vaccinate’ movement reminds me of car sales people – who each year try hard to give the impression the new model year vehicle is perfectly reliable and problem free, but out of all the cars sold and produced very few are actually turn out to be problem free 20 years down the line.

    Vaccines are the same thing – both in theory and the practice of manufacturing them is complex, and I have significant personal experience with the medical industry. Doctors, medical manufacturers, and others in this field make mistakes more than 1% of the time, that’s a fact that there is factual evidence to support.

    Vaccine proponents on the other hand cannot show factual evidence of benefits to more than 1% of the population. Typically the benefits are very small and require vaccinating a large population to achieve, deposting millions of dollars into the medical industry’s pockets in the process. Is this cost and risk worth the rewards?

    Sure, vaccines are a cool invention, they in the past prevented many deaths. But now they produce new vaccines for a variety of things every year with no proof of any significant benefit. Vaccine manufacturers would have you believe that each of the hundreds of vaccines they market these days is as essential and lifesaving as the half dozen that have helped the human race historically, and that just isn’t accurate.

    My claim is this, 90%+ of vaccine’s are completely unneccessary, and in fact dangerous. Each time you inject yourself with something there are risks. People have every right to know how the vaccines are created, if they are expired, and what they contain. This information is not readily available so who can blame people for not having confidence in this kind of system?

    Personally, I do not allow myself to be vaccinated and when my children are old enough I will allow them to choose for themselves if they would like to be.

    I believe in freedomsand not in trying to pressure, bully and coerce others into doing something, but rather educate them.

    If you can prove vaccines are helpful, show me the evidence and I’ll go get vaccinated myself right now.

    I am a heavily science oriented individual, but the logic medical practitioners use is completely flawed. When I read studies in peer reviewed medical journals I find mathematical and logic errors all the time and conclusions written based upon these. I, frankly, am appalled at how they let people graduate from medical school without a proper understanding of science and statistics. This is why progress is so slow in the medical field, studies often reach the wrong conclusions and need to be repeated many times by many different teams until you eventually figure out what you did wrong.

    Many people, myself included, don’t like doing to doctors for ‘preventive’ reasons because unless I am sick enough to need medical treatment I’d rather stay as far away as possible – statistically, when you go to a doctor or enter a hospital for ANY REASON you increase your chances of infection and death. I’ll say that again – ANY REASON.

    That has been proven by math and statistics in many large long term studies that measure ‘death from all causes’.

    My point is that for all the theory about how good for you vaccines are, the people making them screw it up so often that in practice the odds are not as they appear.

    This is common in medicine by the way – want evidence? Just grab a few random lab test results for random patients off your desk and examine them. How many are outside the normal range? How many statistically should be outside the normal range? And what does the lab claim that the accuracy of the tests are? You will quickly see that it DOES NOT COMPUTE – labs claim the tests are 99% accurate but this is in theory. In practice THEY ARE NOT.

    So if we can’t run a simple blood test, how can you say we can concoct vaccine’s and safely and accurately inject large parts of the population knowing that there will be no long term effects 20 years down the line? Especially if the vaccine was just created and YOU HAVE NO WAY OF KNOWING WHAT IT WILL DO. You have THEORIES, that’s IT. MEDICINE IS FULL OF UNKNOWNS.

    There is more we don’t know than what we do. So it’s quite arrogant to think that everyone should be vaccinated and that this is the right thing to do. The logic being used to come to that conclusion is flawed in many ways.

    Anyway I don’t expect I will convince you, you seem set in your beliefs, but I just want to throw out an opposing view for the sake of discussion/education.

    If you have proof that most vaccines do more harm than good these days, please link to it here.

      • I know I didn’t include all citations, I wasn’t publishing an article just leaving a comment.

        This is a complex subject, but if you ask me about one thing you disagree with the most I’d be happy to respond in detail as much as necessary until we have a conclusion.

        Yes I have read the similar back and forth referenced above by other pro and anti-vaccine people. My response to the assertion that my statements minimizing the importance of vaccines is this:

        Yes I am aware thousands of people die from vaccine preventable diseases. I am also aware of millions of people who suffer from chronic diseases of unknown causes, have serious disabilities and cost society, their families and themselves tremendous suffering. Unlike pro-vaccination folks, I don’t claim that one is a lot worse than the other.

        The two most likely explanations for the epidemic of immunological disorders in recent times is pollution or vaccination. So sure, vaccines are not proven to be a cause of anything bad. It could take the next 100 years to prove that. But these are things designed to mess with your immune system on a long term basis, so how is it logical to assume we have any basis for claiming long term safety?

        I have nothing to gain from posting this. I believe vaccines are harmful and clearly you do not.

        P.S. I reject the claim made in the linked to posts that medical professionals do recognize the risks of vaccination. I’m a parent and when I want to the pediatrician there was no mention at all of any risks – especially the fact that long term effects of various recently produced vaccines are unknown and unstudied.

        And that is not confidence instilling at all, because it shows me they are only trying to push me into getting my kids vaccinated, and they did not provide me with any information about how the vaccine was produced and what steps were taken to ensure that would be safe for me, nor any information about how the risks vs rewards were evaluated.

        BASICALLY THIS WHOLE DISCUSSION COMES DOWN TO THIS:

        Medical professionals have made the decision that it is better for you to eb vaccinated and want you to just trust them that they have made a good decision for you.

        Sounds reasonable, except I don’t trust you because I watch you guys screw things up all the time that are a lot less complex than this.

      • P.P.S. And you are all very arrogant and always think you are right, but each specialist I go to diagnoses me with a different disease in their own specialty. It’s just not confidence instilling at all.

      • Don’t get me wrong, I respect you guys are all trying to help patients. I’m just saying your competency and success rates are nowhere near what you guys arrogantly think they are. Doctors make lots of assumptions, and lots of mistakes they are not aware of. The patients who are suffering rarely have time to contact all the doctors who were wrong to tell them about it, so they continue to think they were correct.

        I have never had a doctor call me to do a long term follow up and ask – so about that thing I diagnosed you with 10 years ago, is it resolved now, how did it turn out, etc.

        So doctors have a very skewed perspective, they just make assumptions that they were right, and probably only hear back from the patients that want to talk to them – the ones that say thanks. The others are pissed off and don’t want to deal with you anymore so you don’t hear from them.

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