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    Seth Mnookin

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3 Questions: Seth Mnookin on research to encourage vaccination

MIT professor co-authors AAAS report calling for dedicated research on vaccination decisions.

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Years after a groundless report linked vaccines to autism, the consequences of the fallacy are still being felt as measles, mumps, and whooping cough spread through undervaccinated communities. Yesterday the American Academy of Arts and Sciences released a report — co-authored by Seth Mnookin, an assistant professor of science writing at MIT — that makes it clear that reversing this trend will require dedicated research on how vaccination decisions are made, and on the best ways to communicate factual information to nervous parents.

The report, “Public Trust in Vaccines: Defining a Research Agenda,” was announced in the journal Science with an editorial written by Mnookin and his co-authors, Barry Bloom of the Harvard School of Public Health and Edgar Marcuse of the University of Washington. “Vaccines are one of the safest and most cost-effective medical interventions in history,” they write. “By immunizing infants, children, and teenagers, vaccines protect the entire community. Nevertheless, there is a surge of outbreaks in vaccine-preventable diseases in the United States. What research is needed to reverse this trend?”

The associate director of the Graduate Program in Science Writing in MIT’s School of Humanities, Arts, and Social Sciences, Mnookin is the best-selling author of “The Panic Virus” (Simon and Schuster, 2012), which examines how inaccurate scientific reports linking vaccines to autism have reverberated through the media. He shared some insights from his new report.

Q. Many of the recent fears surrounding vaccines have focused on a specious report that the measles-mumps-rubella (MMR) vaccine was linked to autism. That report was retracted several years ago and its lead author was stripped of his medical license. Are people still worried that vaccines will harm their children? 

A. Unfortunately, they are — although it is very important to point out that overall, vaccination rates in the United States are extremely high: over 90 percent for the MMR vaccine and varicella and over 94 percent for diphtheria-tetanus-pertussis. 

But if you’re living in a community, or your child attends a preschool, where only 70 percent or 80 percent of kids are vaccinated, the overall U.S. vaccination rates aren’t going to help you very much. We’ve seen tangible evidence of the consequences in diseases outbreaks over the past several years. 

In 2011, the United States experienced its largest number of individual measles cases (222) and outbreaks (17) since 1996. The initial case in virtually every one of these outbreaks was someone who was intentionally unvaccinated, or someone of unknown vaccine status. In 2013, 187 more cases were reported; 58 of those made up the largest outbreak in the United States in 17 years. All of this is especially notable because in 2000, the World Health Organization declared measles functionally eliminated in the United States. 

Those infections were obviously awful for the families affected, but they also have a real impact on the ability of public health officials to operate in those communities. A study of a 2008 measles outbreak in San Diego found that containing each individual case cost more than $10,000. That’s a lot of money that could be spent elsewhere. 

Q. The American Academy of Arts and Sciences conference you co-chaired — as well as this report, which emerged from the conference — doesn’t propose particular solutions to the vaccination problem. Instead, you and your co-authors outline the research questions that could provide the data to best address the fears parents have about vaccination (otherwise known as “vaccine hesitancy”). Why did you take that approach?

A. In the years after my book, “The Panic Virus,” was published, I was asked to take part in a number of workshops in which the participants discussed strategies for confronting vaccine fears spurred by misinformation. After attending several of these gatherings, I realized the approach was somewhat hypocritical: Here were some very smart people essentially talking about their instinctual responses to addressing the fact that some parents rely on instinct rather than data to make decisions about vaccination. 

At one of these conferences, I met Edgar Marcuse, a professor of pediatrics at the University of Washington and a former chair of the Department of Health and Human Services’ National Vaccine Advisory Committee. We kept in touch, and when we were both invited to join an initiative on vaccine hesitancy at the American Academy of Arts and Sciences, we joined up with Barry Bloom, a former dean of the Harvard School of Public Health, and essentially said we’d love to be involved so long as the project focused on identifying the types of research questions that would provide data-based answers to critical questions, such as: When and how are attitudes and beliefs about immunizations formed? When are parents or prospective parents most receptive to learning about vaccines? How can providers best respond to parental concerns? Is there any way to identify communities most at risk of vaccine-preventable disease outbreaks? 

After those initial discussions, which took place some two years ago, Ed, Barry, and I assembled a pretty eclectic group and got to work. Some participants were the exact types you’d want and expect at a discussion about these issues: an epidemiologist from the Centers for Disease Control and Prevention, the head of the National Vaccine Program Office, the head of the Massachusetts Department of Public Health’s Division of Epidemiology and Immunization, and the associate director of the Emory Vaccine Center. In addition, we invited leading thinkers in risk, marketing, and health communication. The assistant director of the Harvard Opinion Research Program was there, along with a nurse practitioner from CVS Caremark. 

The bottom line was that since Ed, Barry, and I knew we would not be conducting the new research ourselves, we hoped the report could highlight why it was needed — and potentially help researchers interested in these issues advocate effectively for funding and support for their work.

Q. What other indications are there that this type of research is needed? 

A. The most obvious evidence is that outbreaks of preventable diseases are continuing to occur across the country. There are also indications that some of the current strategies being employed are counterproductive. For instance, I’ve seen a lot of vaccine advocates stress that vaccination refusal rates overall are on the rise, as apart from being on the rise in specific communities. Not only is that not necessarily true, but that message risks normalizing vaccine refusal. If parents know that between 90 percent and 95 percent of their peers are vaccinating their children, that’s a pretty powerful message. 

Here’s another example of why research is needed: The public health community has long assumed that misinformation about vaccines has to be confronted head on; however, there’s some research indicating that might not be advisable. Cass Sunstein, a Harvard Law School professor and former head of President Obama’s Office of Information and Regulatory Affairs, has written that there is an asymmetry between increasing fear and decreasing it. In fact, he concluded that the best response to addressing fears might be actually to simply change the subject. That’s the opposite of the tactic currently in use. 

Story prepared by MIT SHASS Communications
Editorial and Design Director: Emily Hiestand
Senior Writer: Kathryn O'Neill
Communications Assistant: Kierstin Wesolowski

Topics: Public health, Autism, Science writing, Vaccines


Thank you for your continuing work in vaccine advocacy, Seth (and I hope you don’t take my comments here the wrong way).

As a pediatrician who has seen this continual decline in vaccination rates due strictly to parental refusal, I do not believe that we have truly "confronted head on" vaccine misinformation. By ‘we’, I do not mean us as individuals (you, Dr. Paul Offit, Dr. David Gorski, me, etc), for as individuals have been working so hard at vaccine advocacy this last decade. The difficulty is that the public doesn't care so much what an individual says on behalf of vaccines compared to what they see online (and on billboards, planes and buses) from anti-vaccine groups like the NVIC (National Vaccine Information Center). I think we all agree that people now get so much of the information (and misinformation) they need to make decisions from online sources. Go to the NVIC web site and you will find vaccine misinformation galore. If you search “AAP" (the American Academy of Pediatrics) on the NVIC web site, there are over 100 hits, many of them showing how the NVIC is not scared of the AAP. Well, they don't have to be, because if you go to AAP.org or healthychildren.org (the two main AAP web sites), there is nothing on the NVIC. The same asymmetry holds for the NVIC and CDC. While the NVIC is more than happy to pummel the CDC at every opportunity, the CDC (like the AAP) has essentially (for this last decade) adopted the "ignore/change the subject" approach with regards to the NVIC. Finally, (and you know how strongly I feel on this, Seth), two very anti-vaccine FAAP pediatricians--Jay Gordon, MD, FAAP and Robert Sears, MD, FAAP have garnered publicity and large monetary profit selling their anti-vaccine books and webinars without any opposition from the AAP, CDC, AMA, AAFP, etc. What else could a parent think if they are looking online to see if any professional group opposes Gordon/Sears and finds no one has? Sears and Gordon are Fellows of the American Academy of Pediatrics and say things completely opposite CDC/AAP immunization policy—yet the AAP not only tolerates them but gives them full fellowship. That parent is going to fall for the vaccine misinformation of Sears every time, doing so under the reasonable assumption that if Sears or Gordon really were doing something wrong, then they AAP wouldn’t let them be members or would have at least spoken out against them. I assert that there needs to be some public calling out and shaming of those in the anti-vaccine camp most responsible for spreading lies and fear--and that has to come loud and clear from a group like the AAP or AMA or CDC. I also assert this needs to happen first before we go off and do more research.--Chris Hickie, MD, PhD

Dr. Hickie's comments above illustrate the unsophisticated and unscientific approach currently taken by public health organizations in promoting vaccination:

(1) assume that all people concerned about vaccine safety are well represented by the loudest and most extreme vaccine skeptics, and are thus dangerously uninformed or irrational (this is something like assuming that all people concerned about environmental pollution are well represented by those who blow up biotech labs);

(2) divide the public into two groups, one including those who trust and follow the latest risk analysis and vaccination schedule published by the CDC in every detail without question ("responsible people"), and one including those who do not ("anti-vaccinationists," all of whom Dr. Hickie feels should be publicly shamed, even if their recommendations are largely similar to current or past CDC recommendations);

(3) in addressing the public, avoid mentioning weaknesses or uncertainties in current vaccine safety research (thus assuring they are not addressed), to avoid lending any credibility to the "anti-vaccinationists."

If you dig deeply past the fear-mongering PR of "anti-vaccine" groups, you will eventually find sober discussions of legitimate scientific concerns, such as: lack of independent inert-placebo-controlled vaccine safety studies in relevant populations, especially with long-term follow-up; lack of empirical measurement of injection pharmacokinetics for many vaccine ingredients; lack of public health impact analysis for alternatives to the CDC vaccination schedule in timing or subpopulation differentiation; and even lack of theoretical understanding behind many fundamental details of the vaccine mechanism itself (which relates to theoretical concerns about long-term consequences for immunity, including auto-immunity).

More broadly, you will find that the guiding objectives behind public health policy decisions are almost solely the population-level numbers---overall annual cases and deaths directly attributable to contagious disease---with little to no consideration to minimizing lifetime risk for any given individual. The former clearly dominates the political pressure, but it is the latter that parents actually care about. Some may be convinced that the health of the overall population---including the most vulnerable people---should take precedence over making the best decisions for their children alone, but this is a tough argument to win all the time. As long as public health organizations avoid distinguishing between individuals, they will have no way to resolve this essential tension.

I hope that Prof. Mnookin's new research program will focus on the many educated and clear-minded people who have reasonable doubts about risk management in the current vaccination program, but who almost always lack the time, expertise, and information to resolve these doubts to their satisfaction before making decisions for their children. Public health organizations resist discussing the details for fear of confusing uncritical people, but the uncritical people will ultimately follow what they hear from others they consider more credible, even if they don't follow the arguments. The biggest long-term problem for the vaccine program is the many real critical objections that cast shadows on its legitimacy, and which a program of this scope and importance can afford to much more proactively address.

I will assume that the Thomas Coffee posting here is the Thomas Coffee who has a Ph.D. in Aeronautics & Astronautics at MIT, To that I say congratulations, as I myself have a BS in physics and love all things scientific. However, I take offense at your labeling current approaches taken by public health organizations as "unscientific and unsophisticated", and I humbly suggest you are commenting well outside your area of expertise when you use such terms in a blanket manner. The overwhelming body of research clearly shows that vaccines are safe and effective against diseases that continue (in unvaccinated parts of the world) to maim and kill. It's also being clearly shown the resurgence in vaccine preventable diseases in the US is directly due to declining vaccination rates, especially in areas of clustering of anti-vaccine families. It is odd, Professor Coffee, that you work in an area of science that has one of the highest occupational death rates for those who travel in one area of your expertise (i.e. astronauts in space vehicles), yet you are so critical of vaccines--which have been shown to have saved millions of lives and even eradicated entire diseases. Perhaps all astronautics and aerospace research activity should be put on hold until you and your colleagues can sit down and make things 100% safe for people in rockets (or even airplanes for that matter), as it has well been known that any type of flight is inherently risky and can result in injury and death. I think you need to understand that people with technical expertise in one area aren’t often experts in other areas, and they really need to be careful about what they say in areas outside their expertise. I'm not going to design a deep-space vehicle any time soon, and I don't think you’re really going to become an expert in public health and vaccine policy anytime soon, either. For your further consideration, I highly recommend you read "The Death of Expertise" written by Professor Tom Nichols at The Federalist. Public Health does not need non-expert scientists like you dabbling in this simply because you think you can. My initial comment on this article was meant to address my concern that I don’t think those of us in healthcare have done all the initial education and outreach on vaccines that could have been done before we go looking at new ways to educate the public on vaccines. I’m not sure why you feel my post necessitated you to launch into typical “intellectual” anti-vaccine screed that I often see from outside scientists have an ax to grind on vaccines.

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