February 3rd, 2015

A Few Remarks About Vaccines

Political discussion of vaccines has increased recently in the wake of a highly publicized outbreak in Disneyland (the one in California). The discussion is rarely framed as a political conversation, but it is about what we should do as a group, whether as parents, believers in science or alternative medicine, citizens of the United States, etc. When we are talking about what we as a group should do, we are talking about policy. When we are talking about policy, we are engaging in political discussion.

There has not been a lot of polling on the topic of support for vaccination. Many of the poll questions on the topic have been written in a way that a person who _supported_ vaccination programs as they currently exist would have responded in a way perceived as _anti vaccination_. For example, vaccination in this country is not mandatory for all children, and there are well-known, scientifically and medically well-supported reasons for not receiving some or all of the standard vaccination program on the standard vaccination schedule. Scientific and medical research clearly supports these exceptions -- if we were to get rid of them, we would dramatically increase both the negative effects of vaccinations and, for really good reasons, resistance to vaccination in general.

Related -- but not identical -- to well-supported exceptions to vaccination programs is the issue of negative reactions to vaccines on the schedule. Negative reactions to vaccinations ARE COMMON -- that is, a typical vaccine will generate a worrisome reaction in the recipient often enough so that if you actually have friends with kids and you talk to them openly and honestly, you have heard about these reactions. These aren't a secret. They are on the data sheets. If you have kids, and you got vaccinations for your kids, you read about these side effects, whether you remember it or not. I'm going to point to a few of these here:

I'm using the WHO sheets for now.

http://www.who.int/vaccine_safety/initiative/tools/MMR_vaccine_rates_information_sheet.pdf?ua=1

"Systemic reactions includes fever >103º/39.4 ºC occurs in about 5 to 15% of vaccine recipients between the 7th to 12th day after vaccination and lasts approximately 1 to 2 days. In some cases, the fever may be coincidental, due to other infections. Measles vaccination also causes a rash to occur in approximately 2%-5% of vaccines. The rash typically occurs 7–10 days after vaccination and lasts about 2 days."

When a child has a fever of 100 degrees or more, they are often not allowed to go to group day care/school; similarly, with a visible rash. They will not be allowed to go to group day care/school until the rash and/or fever has been gone for at least 24 hours. The effect of giving the MMR is to require someone to be able to stay at home with the baby until the fever has passed -- for 1 in 20 to 1 in 8 of recipients. True, sometimes that would have happened anyway. Also true, a child who got any of the diseases intended to be prevented by the vaccine would result in a lot more time off work for an adult caregiver. However, people who say that this is _rare_ are wrong. It is not rare. People who think that a fever of 103 or greater is not distressing to a parent are horrible people. True, the underlying diseases would be worse. However, dismissing the concerns of parents who vaccinate their children and experience these mild adverse effects tends to create an population of people who feel their concerns are not being attended to. If we acknowledged this more openly, and included these "mild" but distressing (and work-impacting) effects of vaccinations as part of the discussion, we would be more likely to arrive at a mutually agreeable decision about what the group as a whole should do. Here are some things we could talk about doing that might change the debate: encourage people to "time" the first MMR dose to minimize work impact if the child has a fever that requires a parent to take time off work, create an insurance benefit that covers lost income/job loss associated with missed work due to side effects of MMR, write laws protecting the jobs of caregivers who miss work for a few days because of common side effects of MMR.

While MMR is currently the subject of elevated political interest, DTP and DTaP have also been of elevated political interest in the recent past. Pertussis is the underlying disease protected against by DTP/DTaP which babies and young children are most likely to encounter. However, you cannot get a pertussis only vaccine and we haven't even _studied_ a pertussis only vaccine for adverse effects, whether in the cellular or acellular formation. This is a ludicrous gap in the science underlying vaccination that should be corrected at the earliest opportunity -- but that won't happen as long as we focus on how awful it is go get whooping cough, how incredibly contagious whooping cough is, and how we've had effective vaccinations against whooping cough since well before most of our parents were born.

"There are no safety studies that have evaluated the safety of pertussis vaccine when used as the only vaccine antigen. The evidence that pertussis antigens account for a number of adverse events are derived from studies which have compared adverse events following DPT vaccination and DT vaccination. The adverse event information for pertussis is therefore presented under the section on DTP vaccine combinations below."

As long as we treat this as a political problem best solved by yelling at each other, we are unlikely to consider the possibility that the political problem could gain new solutions through technical approaches such as more research to better understand the vaccine that is believed to cause the most side effects in this combination, and the second most side effects of any vaccine currently on the schedule.

"A prospective study of adverse events 48 hours following DTP compared to DT vaccine in children 0 – 6 years showed that the reaction rates associated with DTwP vaccine were local redness, 37.4% local swelling, 40.7%; pain, 50.9%; fever, 31.5%; drowsiness, 31.5%; fretfulness, 53.4%; vomiting, 6.2%; anorexia, 20.9% and persistent crying, 3.1%. These were five times higher than the DT vaccine (Cody et al., 1981; Kathryn et al., 2008). Review of post-licensure passive surveillance data from the United States of America demonstrated that that the reporting rate of AEFI following DTwP vaccination is double that of DT vaccine (Stetler et al., 1985) - 70.8 per million doses administered vs. 38.4, respectively. These findings were consistent with clinical studies."

You may do better reading this than me, but what I see here is about a 1 in 3 chance of fever, and a 1 in 20 of vomiting -- both things that again require a parent or caregiver to be available, as most children are not allowed in school or day care with these symptoms. That "persistent crying" symptom is a lot worse than it sounds, too.

DTP/DTaP and MMR are the two most controversial vaccines currently on the schedule (there was a rotavirus vaccine for a while, I cannot recall if it was optional or not, but it caused so many problems they took it off the market and all rotavirus vaccines since that one have been subject to a very high degree of testing before being allowed out in the wild). They are controversial for a really good reason. Most parents, pediatricians and commentators present vaccines as "no big deal" and opposition to vaccines as being "anti-science", believing the earth is flat, and similar. The general impression a new parents has of vaccines is that there is rarely any kind of reaction at all, and if there is illness after the vaccination, it was coincidental. Reporting a vaccine reaction tends to generate hostility and disbelief from health care providers, who, predictably, are highly committed to a belief set that what they are doing does not cause fever, vomiting and rash in children.

It is not surprising that intelligent, resourceful, educated parents who have the 1 in 20 or 1 in 3 child that runs a fever after every DTP or DTaP shot, or throws a rash after MMR or has a high fever that is difficult to bring down after MMR, will go out and talk to all her friends and then start engaging in activism against vaccines. Because she knows, after talking to all her friends, that other people are seeing these reactions, too.

Do not frame these parents as crazy. Because they have _already_ concluded that the people who should know -- the doctors, the scientists, the regulators, the elected officials -- are lying to them. All you can do is join Team Evil in the minds of parents whose children had a negative reaction to a vaccine which was dismissed by everyone around them.

What you _can_ do is say, YES, negative reactions to vaccines are not rare. They happen to 1 in 20 kids who get the first MMR shot. I'm so sorry your child was one of them. They happen to up to 1 in 3 of kids who get any pertussis shot. I'm so sorry your child was one of them. We really should provide more information and support to parents of children who experience these negative reactions, so they don't lose their job, or fear that the seizures experienced as a result of that high fever are not going to lead to a lifetime seizure disorder. And we should devote more money and resources to coming up with improved vaccines that have fewer side effects.

But most importantly, we should be studying whether or not more adults who were vaccinated as children should be receiving more boosters as adults. Because if we have a bunch of adults running around thinking the solution is to vaccinate ever younger babies, when in fact the _adults_ are the unprotected component of the population, we really are Team Evil.

Link Fu about serial number capture in ATMS

Expect updates.

Recently, I speculated about serial number capture in ATMs. I asked the nice lady at my bank and she said that at my bank, they have no such thing and the ATMs are not cash replenishing either (she didn't know what that was initially). For what that is worth.

https://www.linkedin.com/groups/How-many-banks-in-your-823497.S.125188033

"Eduardas Vaigauskas

General Manager at Cashphenix International LLC

In some countries (Turkey f.e.) recycling ATMs from GRG are equipped with this function "as standard". It is always the choice of the user to print or not to print serial numbers on the receipt. Using GRG Banking Equipment recycling ATMs it is possible to capture serial numbers of notes and store them in DB to be used in different application."

"Ahmad Hassoun

Senior EFT Specialist at BLOM Bank

Yes we have this feature within our ATMs where it prints the serial number of the notes in the cash deposit module.We do track these notes which have been deposited by the customer."

Others noted that serial number capture was useful in detecting counterfeit notes. Others had never heard of serial number capture in ATMs but wanted to know more (model numbers, etc.) once they found out it existed.

Tabletop counters with serial number capture may be older than I thought. I thought they dated from 2011, but this suggests maybe a couple years earlier, at least.

http://www.currency-news.com/trasforming-cash-processing

GRG is taking front and back pictures as well as capturing serial numbers.

http://www.grgbanking.com/en/show_news.asp?id=2246&type_id=21

R. notes that anyone doing envelope free deposits of checks and cash are having to do something along these lines anyway so why not use it more generally.

A POS patent from 2003, with silent alarm, serial numbers recorded for all bills released under duress, etc.

http://www.google.com/patents/US6550671

TRMS on vaccines

Wow. Really, really stupid summary. Maddow described the recent outbreak as a 19th century style outbreak.

Okay. Let's visit wikipedia on the subject of measles.

http://en.wikipedia.org/wiki/Measles_vaccine#History

"In the United States, reported cases of measles fell from hundreds of thousands to tens of thousands per year following introduction of the vaccine in 1963 (see chart at right). Increasing uptake of the vaccine following outbreaks in 1971 and 1977 brought this down to thousands of cases per year in the 1980s. An outbreak of almost 30,000 cases in 1990 led to a renewed push for vaccination and the addition of a second vaccine to the recommended schedule."

You don't have to go back to the 19th century, just the 20th. And honestly, if there were still 30,000 cases a quarter century ago (hey, I remember that quite vividly, actually), we really shouldn't be acting like this is all that big of a surprise.

We've known for a while now that the big risk with measles is when overseas epidemics are transmitted to the US by tourists in either direction. The Philippines has been struggling with a lot of cases (as has China -- the WHO puts together a nice map so you can see where the problems are). We should be focused on getting vaccination up in places like the Philippines -- where some provinces have rates as low as 50%-60%.

We can no longer act like our country can be made pristine and safe by actions taken within our borders. We need to focus our efforts where the need is greatest. (Altho I'll stick by my assertion that there are probably some adults who could use a booster or two here in this country.) Rhetoric which suggests that endemic measles is something in our distant past is not going to help us address this problem. Rhetoric which acts like the current outbreak is anything like as scary as what most people in this country ought to be able to remember (1990 was 25 years ago, and median age in the United States is 36 and change) is also distinctly unhelpful.

Here, a little reading for people who have forgotten in the early 1990s.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022280/

[ETA: I think we fixed the 1990 epidemic problem ultimately by making vaccines close to mandatory to participate in school. My husband observes that our state -- and presumably many others -- also completely removed cost obstacles to receiving the standard vaccine schedule.]

[ETA: Contemporary documentation of the 1990 new rules for going to school, from NY: https://www.suny.edu/sunypp/documents.cfm?doc_id=55]

[ETA: Well, _this_ is very sad! http://www.wpro.who.int/philippines/mediacentre/features/immunization_campaign/en/ As wonderful and important as it is that WHO and DOH worked together to do a mass immunization of every 0-5 in the country against polio and 9 months-5 against measles and rubella, they did that in 2011, too, and it helps -- for about a year. And then measles gets going again. We need to help the Philippines solve the routine vaccination problem -- either that, or we'd better figure out a way to make the mass vaccination system work a little more often than every 3 years.]