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Wednesday, February 18, 2015

Thinking About the MMR Vaccine - by my husband, Jared Ostermann

            There are a lot of people out there willing to become angry, attack my parenting, make unfair judgments, and call me silly nonsensical names (“anti-vaxxer!” “science denier!”) if I exercise my right as a parent not to vaccinate my child against a particular disease or set of diseases. I think this says a lot about them - and their lack of perspective, common courtesy, and respect for other human beings’ rights, beliefs, and privacy - and very little about me. So, I’d like to say a little about me and post it on the internet. I’m sure that even the sentences above are already marked “TLDR” in many peoples’ minds; but I’ll forge ahead anyway and try to keep things short.  I’m also sticking to Measles here because it’s the current fad disease we are told to worry about. And because my wife and I are not “pro” or “anti” vaccine - rather, we evaluate each disease or set of diseases separately when making vaccine decisions. Sometimes we say yes, sometimes no. Here is some perspective on why we don’t do the MMR vaccine:

I’ll set up some numbers first.

I have three children, ages 6, 4, and 2 years old.

How many children are there in that age bracket in the United states? According to the 2010 US Census, there were 20,301,262 under 5 and 20,348,657 from 5-9 years old. To keep things simple I’ll lump the ages together and say 40,649,919 between 0 and 9.

How many are vaccinated? According to the CDC’s 2013 National Immunization Survey, the national vaccination coverage rate for MMR is 91.9%.

What is 8.1 % of 40,649,919? Answer: 3, 292,643. OK so far? I think it is safe to say that there are about 3, 292,643 children ages 0-9 in the United States that have not had the MMR vaccine. The smaller this number the weaker my argument, so I’ll round down to 3,200,000

Next question: how many unvaccinated 0-9 year olds got Measles in the US last year? This is a bit harder to find out exactly, but for the purposes of this summary I’m ok with any rounding off and simplifying that weakens my argument.  According to the CDC there were a total of 644 cases in 2014. I will take the number 644 as a starting point, even though it is significantly higher than the average for the last decade. According to the CDC, “most” cases were unvaccinated, so for my purposes I can simplify by saying “all cases” were the unvaccinated. How many were 0-9? The closest I can find through the CDC is statistical summaries from January-August of 2013, and January-May of 2014. In the 2013 report, 72% were under 19 years old. In 2014, 48% were under 19 years old. Well, that’s kind of a big spread, and the 2014 report, being in May, analyzes less than half the cases from that year. I guess I will take the high end and say 70%, even though this is the 0-19 years old set rather than my smaller subset of 0-9. What is 70% of 644? We’ll round up to 451, really a silly number given all my rounding up and the doubly large age bracket, but it’s something to work with. So I’m guesstimating 451 unvaccinated children ages 0-9 with measles in 2014.

OK now some basic probability analysis. What is the chance of my unvaccinated 0-9 year old getting measles, based on these numbers? It is 451/3,200,000, or .0001409375 or, as a percent, .0141%. In other words, about 1.5 in 10,000 unvaccinated children will get measles. Pretty unlucky, but it is a chance.

Now another statistic - what is the mortality rate of Measles in the US? The CDC gives the answer 1 or 2 in 1000 children, so I’ll take the (2x) higher number of .2%. 

Remember elementary probability? To find the probability of two independent events BOTH happening you multiply their probabilities together. The probability of a perfectly fair coin coming up heads is .5. The probability of getting heads twice is .5 x .5, or .25. What is the probability of BOTH A (getting measles, .000141) and B (dying, .002) happening to my unvaccinated 0-9 year old? Answer: .000000282, or .000028%, or about 3 in 10 million. 

Next, I’ll make two assumptions that hurt my argument, in order to continue this discussion:
1 - I’ll assume the MMR vaccine is 100% effective
2 - I’ll assume that my breastfed, healthy, non immuno-compromised, non-daycare and non-public school children share this general .000028% chance of dying from measles.

I will also leave aside Measles complications for the moment, since the truly scary ones are actually less likely than death. According to the CDC Encephalitis is at .1% probability, and Subacute sclerosing panencephalitis (the stuff of nightmares - this may actually be worse than death) is at .001% (5-10 out of ten million cases). It’s funny to me how often those two complications are mentioned by people trying to make the point that measles is serious, when they are less likely than death. Death is a scary enough complication - let’s stick with that!

So where does that leave me as a parent? Is there a risk of death from not vaccinating? Technically, yes. We have found an actual number that does exist, so there is a chance. As Jim Carrey put it:

He’s right, technically, and so are vaccine advocates when they try to scare me into vaccinating. But the question is, is a 3 in 10 million chance something that any rational person would fixate on? Am I actually frightened of a .00003% chance of death for my children? No, not really. In fact it doesn’t even make the list of fears that consciously register with me as a parent. What does scare me? Well, according to the National Institute of Health Statistics 2013 life table the probability of dying between age 1 and 5 is .1 % and the probability between age 5 and 10 is .05 %. Put another way, if I am worried that my child might be in the .1 % that dies (and what parent isn't), there must be many, many risk factors that are exponentially more important than measles. Such as basically any other disease or health complication you can imagine (especially the top killers of heart disease and cancer). But since my children have checked out fine so far from some of these actually scary possibilities, there is also the risk of accidents of various kinds - drowning, choking, SIDS, traffic accidents. If you go to the Health Statistics table above and scroll down to table 11, you can find the national death rate by cause and age for all kinds of interesting things. For example, the chance of my 1-4 year old dying by accidental drowning and submersion is 2.5 per 100,000 or .0025%. Actually, that’s not as high as I expected, but still 100 times more likely than my inflated odds of measles death above. The death rate for motor vehicle accident death is about the same for my 1-4 year old - 2.7 out of 100,000. One of the highest rates is simply titled “accidents” and is 8.3 per 100 thousand. Look, we could go on with this all day (that’s a very interesting table). But the bottom line is, there are countless things in the world more likely to cause my children’s death than even my absurdly pessimistic measles estimate above. Are there practical ways I can reduce the chances of death by drowning, choking, or accidents in everyday life? Definitely, and to be honest I’m a bit obsessive compulsive about patrolling the house for baby chokers, toys on the stairs, tripping hazards, open bathroom doors, being sure to cut food into tiny bites, and so forth. It seems rational to me to look for ways to reduce risk as a parent, especially from these kind of everyday hazards that are some of the leading causes of death. It does not seem rational to me to analyze every kind of risk I can possibly imagine, and obsess about things that have an almost nonexistent chance of harming my kids. Yes, risk is incurred by avoiding the vaccine - but only in the technical sense that we can guess at a tiny probability; not in the sense that avoidance is a dangerous activity, by any sane definition of the term.

But Wait! Why take even this tiny risk if it is avoidable through the MMR vaccine?

Well, if the vaccine were absolutely 100% safe beyond any doubt, then I suppose there would be no reason at all NOT to take it. Although, just as a matter of principal, I might still argue against obsessively chasing around after every .00003 % death probability we can think of. But the fact is, there are complications. I’m not talking about autism, I’m talking about the rare and generally not serious complications officially noted by the vaccine experts. It’s interesting that the CDC considers their rarity a good argument for ignoring them, while the tininess of risk from the disease is typically dismissed as an argument. This is where sleight of hand with basic probability comes into play. Official statements from the experts and CDC will typically discuss the probability of independent events. So for example, the probability of complications from measles is measured against the probability of complications from the vaccine. And of course, complications from the disease are far more likely than complications from the measles vaccine. I should hope so! Otherwise the vaccine would be a pretty silly idea. Or, the pamphlets will compare the possibility of getting measles with the possibility of vaccine complications. Again, this is a no-brainer. You’re exponentially more likely to get measles than to have a vaccine complication. Finally, they will point out that you’re much more likely to avoid the disease if you’re fully vaccinated. Again, I would hope so! But the difficulty is that to have a real problem I have to have two independent probabilities both line up: first, the probability of getting a rare disease, and second, the probability of getting a serious complication from it. That’s what I've looked at above. I have read dozens of statements and websites and pamphlets from the professionals, and not once have I found someone compare the chance of getting a severe complication from measles (again, a combination of two probabilities) with the chance of a severe vaccine complication (only one probability because vaccine reception is a given). Why would this be? Probably because both numbers are so tiny that neither really has compelling weight as a motivator for a regular person. I could go on at length about the rhetoric of the vaccine-advocate camp (by the way, I find “advocate” a more helpful label for others, since I am “pro-vaccine” in the sense that I am glad we have this technology and would use it for myself or my children in many cases, but I do not advocate for universal vaccine use in a political or philosophical sense). But I will just stop here and say that I find the use of probability in vaccine-advocate literature misleading. From looking at the numbers I conclude that there is a tiny chance of danger from not vaccinating, and also a tiny chance of danger from vaccinating. Thus, for me, this is a tempest in a teapot - and certainly nothing to provoke hateful, childish exchanges online. I would never judge another parent for subjecting their child to the tiny danger of vaccinating, and I expect a similar courtesy to be shown to me if I prefer the tiny danger of not vaccinating.

Before I leave the numbers behind, I’ll just respond to one other line of argument from the vaccine advocates. They often say “that’s all very well for your kid, but you have no right to subject other kids to the danger of measles.” I will leave aside the philosophical discussion about whether we have a moral imperative to band together as a species to rid the natural world of any organism that might possibly harm us, although it is such an interesting topic in many different ways. Mosquitoes, for example - but no, I’ll resist the temptation! I will also avoid a lengthy debate about utilitarianism, although that is interesting as well. Many vaccine advocates take utilitarianism (the most good for the most people) as an incontrovertible given, but in reality there is a great deal of human thought surrounding that term. Here I will just admit that yes, we can guess at a certain danger to others from my not vaccinating. It is difficult to conceive of the probabilities at play here, but I’d be interested to see the model. For people who do vaccinate, you would have to take the percentage who do not develop immunity (I believe around 3 %), then run the numbers again: the probability of my child getting measles, times the probability of him/her passing it to a non-immune vaccinated person, times the probability of serious complication or death from this particular case of measles. Alternately you could find the number of vaccinated people who get measles, divided by the total vaccinated population, blame 100 % of that on non-vaccinators (leaving aside international guests and those who transmit the disease because they were vaccinated), and multiply the probability by the death/complication rate of measles. There is an even smaller subset of people are not immune because they, for medical reasons, COULD NOT vaccinate but wanted to, and you could attempt to find out how many of them got measles, blame that 100 % on non-vaccinators, and try to find a number. Here is a preview of all of the above activity: the numbers will be even smaller than what I came up with for my own children. And involve a great deal of guesswork at that. The day someone can, with a straight face, compare these estimated numbers with the potential harm to others of a variety of everyday actions (such as, for example, allowing your 16-year old to drive), I suppose we can at least have a rational discussion about them.

But Wait! The numbers are only so tiny because 92 % of the population vaccinates! And we have all but eradicated the disease! If you don’t vaccinate, you will return us to a situation where many more people get the disease, thus completely changing your analysis. And killing innocent people in the process!

This is an interesting argument, and I have a couple of things to say about it. First, I make my decisions about my child’s health based on reality. And the numbers I’m talking about are the numbers right now, in the real world, where we have all but eradicated the disease and most choose to vaccinate. So in a way this argument is saying “you’re right, but only because your data is factual!” What this argument seems to imply is that I am obligated to make family health decisions based on a potential but as yet nonexistent set of data points. And in response, I make no apology for basing my decisions in reality. But for the sake of argument, it can be interesting to imagine potential future outcomes. For example, is it likely that vaccine rates will increase, decrease, or stay the same in the future? I don’t have a crystal ball handy, but given the hate, name-calling, and public shaming doled out to those who choose not to vaccinate, combined with our general cultural tendency to “go with the flow”, I don’t have any real expectation that rates will decrease significantly in the future. Most people don't want to deal with all of that societal pressure, let alone an argument with their family physician. And I have no problem with that, since I am not “anti-vaccine”. I simply view present reality and conclude that MMR is not a necessity for my kids.

But Wait! Your children are then unfairly benefiting from the vaccinations of others, without sharing the risk!

When this comes up, my snarky side wants to reply: “so now you are angry about the risk your children take when they get vaccinated? You have just been calling me names for even suggesting that vaccines could be dangerous!” But in a more reasonable vein, as long as nobody is forced to inject medical treatments into their or their children’s bodies, my conscience is clear. If the top 1 % in America could implement compulsory vaccination, but only for the children of the lower 99 %, I could see a legitimate problem. But in spite of the ad campaigns, media hysterics, peer pressure, and public shaming of non-vaccinators, the choice is (at the moment) still free in America. Thus, when viewing reality I see that we live in a society where most people freely choose (and will most likely continue to choose) to administer vaccines. I do not force anyone to inject anything into their children. But seeing that most people do, for a disease that is already largely eradicated, I conclude that the numbers discussed above hold true and will likely continue to do so. I then make what I consider a good decision for my child. Is this unfair to the vaccinated child? I don’t believe so, given that that child’s parents were free to make what they consider the best decision for their child. "Fair" to me means that everyone had an equal free choice in the matter. I think this would be an interesting point to pursue farther, with questions of “what is fairness?” “is life fair?” “should life be absolutely fair?” “do I have an obligation to do everything possible to ensure that my children have no advantages over other children?” Don’t all parents seek out unfairness with a passion, in the sense that they want good things for their children and there is often heavy competition for good things in life? At any rate, as interesting as the concept of “fairness” is, my quickie answer is above. 

But Wait! This is just for MMR.
Yes, that is what I limited myself to. Because, you see, different vaccines are for different diseases, which each have their own risk factors, mortality rates, occurrence in the population, and so forth. I never said I was “anti-vaccine”; only that I was not giving MMR vaccines to my kids. And that is why you should avoid a hermeneutic of simple-minded labeling when engaging with other viewpoints. If you want to know about another vaccine, you can ask me. 

To conclude:
All of this talk of numbers and probabilities is interesting, certainly, but there is a larger point I will end with. Life is more than the mere analysis and avoidance of risk. Much, much more, in fact. If we could find someone who lives purely via the principal of risk analysis, we would see a paranoid, highly dysfunctional, possibly insane person - whether an analyzer because of insanity, or driven insane by endless analysis. There are lots and lots of ways to die, and in fact we will all die at some point no matter what. Constant reflection on these possibilities is not healthy in a physical or mental sense. I think this is part of what Chesterton was getting at when he said: “Life is far too serious a thing to be taken seriously.”

Every decision we make, every moment of every day, has some inherent possibility of resulting in our own harm or the harm of others. The possibility may be remote - so remote, in fact, that for all practical purposes it exists only in the imagination. Barbara and I hope to take our kids west to Yellowstone National Park someday. What if when we are hiking a Grizzly Bear kills one of them? This is an actual possibility, and in some sense we would be responsible for making a choice with a tiny statistical chance of death. Not to mention the much more dangerous long road trip to get to Yellowstone! Is the trip worth the risk? Maybe I'll get a big anti-bear revolver and we'll hike with that to stay safe. But then I subject my family to a certain statistical risk of accidental firearm death by keeping it in the house. It's easy to see how you could go crazy from this kind of obsession about statistical risk. I often think of risk when buying a flight online. It does flash through my mind that, as small as the chances are, the button I click, selecting a particular flight, might be the choice that kills me. Now, to leave at 6:45 or 7:30 AM? 

The truth is, everything we do is dangerous in some way - even doing nothing, given the health risks of inactivity. But the mentally healthy person handles this daily series of choices with a sometimes intuitive, sometimes conscious prioritization filter. In other words, not every remote possibility needs to be worried about or addressed. What I have above is a conscious, analytic approach. But part of what is at work is simply my relationship with, and knowledge of, my children. I make decisions for them every day. There are people out there who think I am damaging our kids by homeschooling them, or by raising them religious, or Christian, or Catholic, or by not pushing certain subjects or activities on them. These choices, affecting the mental, emotional, spiritual and intellectual formation of my children, are vastly more important than the choice about the MMR vaccine. But speaking of just physical danger, do you let your teenagers drive? Send your kids to summer camps or on scout trips? Enroll them in contact sports? Let them ride a bike? Let them play at friends’ houses? Neighbors’ houses? When do you start them on solid food? Do you feed them a healthy diet? Always? Do you make sure they have plenty of exercise? And so on and so on. We make choices every day that carry a certain danger component for our kids - among them the ones listed above and countless others with much more statistical danger than opting out of the MMR vaccine - based on our relationship with them and our desire for their general quality of life. So all the numbers aside, part of the equation is simply my common-sense assessment that my kids should only be injected with foreign chemicals and biological materials if there is a compelling reason.  A .00003% chance of death is not even close in my mind, sorry. If you want to work yourself into hysterics about that, and call me a bunch of silly childish names, go for it! Just remember, stress increases your chances of an early death! 


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