Tdap vaccine is not linked to autism, just like any other vaccine (including the flu vaccine)

I remember when my dad told me that there was no such thing as Santa Claus. He sat me down and told me that it had been him all these years who had been buying me gifts and placing them under the tree. It was quite a shock to have this revealed to me; it shook my world. I did everything in my power to reason it through. In my head, dad was a liar. Dad wanted to take the credit for the big jolly guy who’d given me all the gifts I’d ask for in the letters I sent him through my dad.

I was 27 years old.

Soon enough, I came to accept the truth. All the evidence was there in the form of my dad’s receipts for the gifts he had gotten me. People had seen him buy me those gifts. Mom swore to having helped him wrap them. The evidence was compelling, substantial, tangible, credible… Santa Claus was no more.

I’m sad to say that this is not the case with the anti-vaccine crowd. You can tell them all you want that vaccines do not cause autism, and that vaccines actually protect from diseases that are deadly and/or disabling. But they will refuse to believe it because their entire ecosystem depends on the belief that vaccines cause autism. Anything short of that sucks away their life, their reason for living.

One such anti-vaccine zealot is everyone’s favorite “kid.” Even with a master of public health degree in epidemiology, he seems to remain convinced that vaccines cause autism. He’s stated on his blog that evidence he saw in school to the contrary is all a conspiracy from the pharmaceutical industry. It seems that, to him, the lies he has been exposed to over and over from a very young age have made up his mind. To him, Santa Claus (i.e. vaccines cause autism) still exists, and it will continue to exist because anything short of that eliminates his reason for living.

Seriously, he doesn’t seem to live for anything other than that. The primary example is a recent blog post of his where he takes a study that clearly shows that the Tdap (Tetanus, Diphtheria, and acellular Pertussis) vaccine doesn’t cause autism, and then he states that the study confirms that the influenza vaccine does cause autism.

Yeah, I was confused too.

His whole argument hinges on one table in the Prenatal Tetanus, Diphtheria, Acellular Pertussis Vaccination and Autism Spectrum Disorder by Becerra-Culqui et al.

This is table 3:

Screenshot 2018-08-14 10.18.59

Table 3 states that women who were vaccinated with Tdap during pregnancy had a similar incidence rate per 100,000 person-years of having an autistic child. Vaccinated women had an incidence rate of 3.78 autistic children per 100,000 person-years while un-vaccinated women had an incidence rate of 4.05. The ratio between the two was 0.98, meaning that vaccinated women had a lower incidence rate than vaccinated. Anything over 1.0 would indicate that vaccination leads to more autistic children being born.

Because this is one study with a limited number of people, and not a study looking at the entire universe of children born, scientists also report the 95% confidence interval (0.98 – 1.09). The 95% confidence interval is a way of us saying, “We are 95% confident that the true hazard ratio in the entire population (the whole of the population) is between 0.88 and 1.09.” Because it includes 1.0, we cannot say that this observation is not by random chance.

But look at how the kid displays the table on his blog:

Screenshot 2018-08-14 10.18.22

Only point out the things that seem to support your argument.

He points out that the adjusted hazard ratio of 0.85 (with a 95% confidence interval of 0.77 to 0.95) is adjusted for, among other things, influenza vaccination during pregnancy. In epidemiology and biostatistics, “adjusted for” means taking it into consideration. Let me give you an example:

Suppose that there are a group of people from Texas and a group of people from Alabama, and that we look at their test scores in biology. The group from Texas had an average test score of 77% while the people from Alabama had an average test score of 89%. You would conclude that being from Alabama leads you to having a better test score, right?

But what if we told you that they don’t teach biology in all schools in Texas? What if we told you that they only teach it in private schools in Texas, and that only 30% of schools in Texas are private schools? And then we told you that they teach biology in both types of schools in Alabama, and that there is a 50-50 split in the proportion of private to public schools in Alabama? How does this change your conclusion?

To reach the proper conclusion, you have to compare apples to apples, and oranges to oranges. You would compare the private school scores in each state to each other, and likewise with the public school scores. This is an adjustment. This is taking into account the differences in the distributions of a characteristic between the two groups being studied.

As it turns out, in the study in question, women who get their Tdap were much more likely to get their influenza vaccine. It makes sense, right? Women who vaccinate in general are more likely to vaccinate in particular. So, in order to compare apples to apples, the researchers adjusted for influenza vaccination. That is, they compared flu-vaccinated women who got the Tdap and flu-vaccinated women who did not get the Tdap, AND non-flu-vaccinated women who got the Tdap and non-flu-vaccinated women who did not get the Tdap.

Taking flu vaccination into account, and the bias that would creep in because women who vaccinate against influenza seem to be more likely to vaccinated with the Tdap vaccine, vaccinating with Tdap is not associated with having a child diagnosed with autism.

So why does the kid think this proves that influenza vaccine causes autism?

It beats me. All they did was make the adjustment to make things equal between the two groups, something every epidemiologist worth their salt should do… Unless you want to misinform the public?

Hmmmm?

He then takes a table from a different, unrelated study and points out to just one result on it as evidence that influenza vaccine causes autism:

Screenshot 2018-08-14 10.35.03

The red circle seems to be his way of saying, “Only this matters! Pay no attention to the whole of the evidence!”

This is another misrepresentation of the findings, and I kind of blame the authors of the study for making the table so busy. Look at the “Variable” column on the left. All that the data circled in red are saying is this:

“Of the 13,477 children whose mothers were vaccinated in the first trimester, 258 (1.91%) of them were diagnosed with autism. Their hazard was 26% higher for an autism diagnosis when compared to children whose moms were vaccinated in other trimesters. However, when adjusting for maternal allergy, asthma, autoimmune conditions, gestational diabetes, hypertension, age, education, race/ethnicity, child conception year, conception season, sex, and gestational age, the hazard of autism diagnosis went down to 20% over children whose moms were vaccinated in other trimesters.”

The fact that the hazard ratio went down after adjusting tells us that there is something else explaining the elevated hazard (risk). Look at what happened in the adjustment in the other trimester groups… Nothing changed. Look at what happened in the adjustment in the “Anytime During Pregnancy” group… Nothing changed. So what could that “something else” be? I’m not an obstetrician, but it’s reasonable to conclude that outcomes measured in the first trimester are different than outcomes measured in the other trimesters.

Finally, look at the reasoning that the kid used. In the first table, because numbers were adjusted for influenza vaccination, then it must mean that influenza vaccination causes autism. In the second, he doesn’t say that all the factors adjusted for cause autism… Because that would tear down his narrative.

I’m not surprised at all by his misunderstanding of all this. After all, to my knowledge, he doesn’t work as an epidemiologist anywhere. Like any good muscle, lack of practice of your epidemiology skills leads you to lose them. Being unpublished, not working as an epidemiologist, and a staunch defender of the so-called autism-vaccine risk leads the reasoning muscle to atrophy.

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What’s with the fear of the flu vaccine?

We’re right smack in the middle of flu season. The number of reported cases, hospitalizations, and deaths from influenza this season seems to be at its peak, meaning that we have about 6-8 more weeks of heavy influenza activity before it all ends. Those are just the reported cases. Not all cases get reported, and deaths associated with influenza in adults are not as closely observed as deaths associated with influenza in children. Many get classified as deaths from natural causes because a flu test is not done, though, many times, the person may have been complaining of flu-like illness.

The best thing we have against influenza is the flu vaccine. It’s not as good as it could be, but it’s the best thing we have. Short of the vaccine, we can also focus on washing our hands constantly, and staying away from sick people (or, if we’re sick, keeping away from people). But all those other things require us to make a conscious effort day in and day out during the yearly epidemic. If you sit and watch people, we’re quite nasty. We scratch our face, wipe our nose or mouth, and we touch things with unwashed hands all the time.

Even before the 2009 influenza pandemic, there were plenty of people who were afraid of the influenza vaccine. They saw a list of side-effects reported during the clinical trials of the vaccine and thought that all of those side-effects occurred at rates higher than stated. They were also convinced by anti-vaccine and anti-science activists that the vaccine was nothing but pure poison. They were told that the vaccine kills when, in fact, the vaccine saves lives.

Then the 2009 influenza pandemic happened and the anti-vaccine crowd had a collective orgasm (allegedly) when it was announced that the vaccine for that strain was going to be “experimental” or approved by FDA under an “experimental” protocol. They went nuts saying that we were being “experimented” on or that we were taking a risk by taking a vaccine that was not “fully tested” before it was given. Those and other statements just made it clearer that they didn’t know what they were talking about, even if they should know better.

A friend of mine gave me the example of pies as vaccine. We know what goes in an apple pie. We know what goes in a cherry pie. The difference in the two is the filling. Likewise, the difference in a flu vaccine is the strains it contains. For the 2009 vaccine, all they did was change the strain. Everything else about the vaccines was the same. It’s not like they went and created a new way of delivering the vaccine or a new way of growing the virus strains. That came later, and those vaccines underwent extensive testing, more than the testing that goes into a vaccine when strains are changed.

The anti-vaccine cultists will say that the flu vaccine has thimerosal. When you tell them that there is a thimerosal-free version, they’ll say that the vaccine has aluminum. (SEE COMMENT BELOW ON ALUMINUM.) When you tell them that aluminum covers the whole world, they say it has formaldehyde. Then you tell them that a pear has more formaldehyde than a vaccine, they’ll come up with some sort of bullshit like “it’s not natural formaldehyde like the formaldehyde in a pear.” Right. Because the body can tell the difference of where the formaldehyde came from.

I really wish that anti-vaccine cult members just stopped lying. That’s all. Stop lying and don’t get vaccinated if you don’t want to. But to lie and misinform so openly and so happily, associating vaccines with just about anything that happens to anyone at any time? That right there will earn you a special place in whatever hell you believe in. And, if you don’t believe in hell, we’ll still laugh at you in decades to come as yet another deluded person who thinks they know more than they do. (I’m looking at you, Sherry Tenpenny.)

What worries me the most is that there are a number of groups of nurses who are trying to stop mandates for them to get the influenza vaccine at their place of employment. On its face, it seems ridiculous that they wouldn’t want to do what they need to do to protect their patients. But, like so many other people around the world, they’ve been convinced of monsters under their beds by anti-vaccine activists. Either that’s the case, or their nursing schools really, really suck.

Either way, fears of the influenza vaccine are founded in lies and misinformation from anti-vaccine groups. Many of those fears are founded on fantasies about toxins and inexistent injuries. While some people do react badly to the vaccine, their numbers and proportions are astronomical tiny compared to the toll that influenza exacts on humanity year after year. Chances are that these people would have had a similar, if not worse, reaction to getting the actual disease.

But I’m preaching to the choir, aren’t I?

Scrub-a-dub-dub, because you’ve been called out

First and foremost, Happy New Year. Here’s to another year of giving you bits of stuff to mentally nibble on as you go about your day. Now, on with 2015…

Remember Peter Doshi, PhD? He’s the “Hopkins Researcher” non-epidemiologist who claims to know more about influenza than epidemiologists, virologists, and other people who have made influenza research their life’s work. He’s presented on influenza at a conference sponsored by an anti-vaccine organization. And, as I told you before, he signed a letter from the “AIDS Rethinkers” stating that the HIV-AIDS association should be, well, “rethought”. It’s nothing more than AIDS denialism dressed as “skepticism.”

Anyway, Dr. Steven Salzberg, who is a Hopkins researcher, took Peter Doshi, PhD, to task:

“First, as Snopes.com has already pointed out, Doshi is not a virologist or an epidemiologist, but rather an anthropologist who studies comparative effectiveness research. He never conducted influenza research at Hopkins. (He’s now an Assistant Professor at the University of Maryland’s School of Pharmacy.) Second, Doshi’s 2013 article was an opinion piece (a “feature”), not an original research article, and it did not report any new findings. Third, it is highly misleading to suggest (as the anti-vax article’s title does) that Doshi somehow represents Johns Hopkins University. At Johns Hopkins Hospital, the flu vaccine is required of all personnel who have contact with patients, as a good-practices effort to minimize the risk that a patient will catch the flu from a caregiver.”

That’s not all, however. Dr. Salzberg asked Peter Doshi, PhD, about signing that AIDS denialist letter:

“Perhaps even more disturbing is that Doshi signed a petition arguing that the HIV virus is not the cause of AIDS, joining the ranks of HIV denialists. He signed this statement while still a graduate student, so I contacted him to ask if he still doubted the link between HIV and AIDS. I also asked him if he supports flu vaccination, if he agrees with the anti-vaccine movement’s use of his statements, and if he believes the flu is a serious public health threat.

On the question of signing the HIV/AIDS petition, Doshi responded that “Seeing how my name was published and people have misconstrued this as some kind of endorsement, I have written the list owner and asked for my name to be removed.” He declined to state directly that he agrees that the HIV virus causes AIDS—though I gave him ample opportunity.”

I, too, emailed Peter Doshi, PhD, a while back (October 2013) and asked this:

“I was recently informed that you have taken the position of associate editor with the British Medical Journal. While doing some research on your work, and seeing what influence you have and will have on evidence-based medical practice, I came upon a website (http://aras.ab.ca/rethinkers.php) which lists you as a signatory to a statement denying the existence of a causal relationship between HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immune Deficiency Syndrome).

I hope you can see how “AIDS denialism” may put into question your judgment of medical and scientific findings submitted for review at BMJ. My questions to you, if I may have a few minutes of your time, are:

– Did you sign that HIV/AIDS statement denying the existence of a causal relationship between the virus and the disease?
– Are you in fact now an associate editor at BMJ?

I extend you much gratitude for taking a moment to answer these questions.”

He never replied, though I never received a notice that the email was not delivered, and I copied him on all known emails he’s used on publications.

On that website, his name was listed thus, a few names under Australian anti-vaccine loon, Meryl Dorey:

Screen Shot 2013-10-04 at 8.41.45 PM

The list looks like this today:

Screen Shot 2014-12-27 at 7.19.17 PM

No more Peter Doshi on the list. It appears that he did as he said he would to Dr. Salzberg and asked that his name be removed. The thing about that page is that it is querying the list from an external database, so we can’t use the “Way Back Machine” or Google to his name when it used to be there. All we have are these screenshots, but, as you can see on Dr. Salzberg’s blog post, Peter Doshi, PhD, never denied signing that letter. (To be a “signatory” you have to contact the list’s administrator, apparently.)

So there you have it. An associate editor at the British Medical Journal has scrubbed his name from a list of AIDS denialists. Do with that what you want. He also doesn’t think the flu is a big deal, so do with that what you want. From Dr. Salzberg’s blog post:

“As for the flu itself, Doshi says “I don’t agree with CDC’s portrayal of influenza as a major public health threat.” So he and I have a serious disagreement there. I asked if he agrees with the anti-vaccinationists who are using his writings to claim that the flu vaccine is ineffective, and he replied that while “ineffective” is “too sweeping,” he has found ”no compelling evidence of hospitalization and mortality reduction in [the] elderly.””

As an epidemiologist doing research into infectious diseases, I will not submit anything to the BMJ for publication for the foreseeable future. I just don’t trust their judgment anymore when they have as an associate editor someone who seems to deny that AIDS is the result of an HIV infection (something 99.999999999% of scientists have agreed on and on whose authority antiretroviral therapy has saved lives) and definitely doesn’t see influenza as a major public health threat. I can only imagine what would happen to any manuscripts I submit on infectious disease.

One more thing…

The HIV “Rethinkers” write thus on their page:

“The next time the media announce that tens of millions of people are dying from Hiv in Africa, ask them how they know that. Remind them that journalists are supposed to question dubious assertions from powerful, drug-industry funded agencies like the WHO, not parrot them as if they were indisputable. Ask them why they report these numbers as if they were actual Aids cases, when in fact they are projections made by WHO’s computer programs, based on very questionable statistical methodologies and contradicted by many facts including the continual large population increases experienced in the countries supposedly worst affected.”

Note the part about the media.

This is what is written on Peter Doshi’s page at his current job with the University of Maryland:

“Doshi also has strong interests in journalism as a vehicle for encouraging better practice and improving the research enterprise.”

Yeah, it should be the reporters that guide the science, not the other way around. Not.

One physician comes back from the dark side, sort of, while another goes over, kinda

Remember that “pediatrician to the stars” that I mentioned to you a while back? The one that has his doubts about vaccines and has even used “The Brady Bunch” as his basis for the severity of mumps? He’s (probably) coming back from the dark side. He posted this summary on his blog of a study on the safety of vaccines. Is he coming back? Is he going to stop it with the questioning of the evidence of the safety of vaccines?

We’ll see. We’ll see.

On the other hand, we have this article from this physician about mandatory influenza vaccination of healthcare workers. Unfortunately, she hits a lot of the anti-vaccine talking points in her disagreement with hospitals’ policies on having their employees vaccinated against the flu:

“But I choose to take the flu vaccine realizing that the vaccine won’t necessarily protect me against all the different strains of the flu virus, and knowing too that I could suffer severe side effects.”

Ah, the “severe” side effects of the flu. You’ve probably heard about them and how “common” they are. (They’re not that common, and they’re not that severe.) The worst side effect from a flu vaccine in terms of mortality is Guillain-Barré Syndrome. It can be very severe and life-threatening, but you can also get it from a viral infection alone. This leads us to believe that it’s not the vaccine, per se, but the immune response to viral infection.

The article continues:

“I’ve always agreed with the general recommendation that people who work in health care should be vaccinated against the flu, but that still needs to be a personal decision, not a government mandate. Each person has individual responsibility to make decisions about safety issues of all kinds — whether or not to smoke, to eat that second piece of cake, to get the tires checked on the car before the road trip. While we acknowledge that bad decisions may put others at risk to a greater or lesser degree, in America we still believe that personal decisions are just that: personal.”

This is the “freedom gambit.” On its face, it makes sense that it’s up to us whether or not to make the decision to be safe. In this case, we’re not making a decision to be safe for ourselves. This is a decision that also affects the safety of others, i.e. the patients. Equate this to washing your hands. It’s your decision, but woe be unto you if you don’t wash your hands in a healthcare setting. You’re placing in jeopardy your safety and that of your patients. I’d say to Dr. Sibert that people who work in healthcare chose to be in a profession where their “freedom” can very well kill people. If she, or others in healthcare, cannot deal with that, they’re more than welcome to exercise their freedom in other professions.

She adds:

“If I should become ill with a strain of influenza that hasn’t been covered by this year’s vaccine, since I’ve been vaccinated I don’t have to wear a mask though I could be quite contagious for at least a day before I develop overt symptoms.”

Well, now we have a quadrivalent vaccine, Dr. Seibert, so you can take that to further reduce this theoretical situation of yours from happening. I mean, the odds of it happening are pretty low already because the way we select the strains to go into the vaccine have been very good for the Type A (and more severe) strains. The type B selection was tricky, I’ll admit it, but the quadrivalent vaccine takes care of it.

Issues of vaccine effectiveness aside, this argument of hers that there maybe, possibly, probably, in some weird situation be a strain that is not covered is hogwash. If there was some big problem with the vaccine not covering a strain, we epidemiologists would make it known to her and her colleagues so that everyone exercises the proper precautions at all times.

And then this:

“No hospital (to my knowledge) is requiring patients’ visitors and families to provide evidence of flu vaccination or wear masks, though they go in and out of patient care areas at will. If we are really to be logical and scientific about flu transmission, either we all should wear masks or none of us should bother.”

Wow! Just, wow! Replace masks with “hand washing” and see where she goes off the deep end on her argument. “None of us should bother?” Excuse me, doc, with all due respect, YOU CHOSE THIS PROFESSION. You also come into contact in a more direct way with a lot more patients that a visitor. And, if you look into isolation precautions, you’ll note that visitors to patient areas where there are severely sick and immune-compromised people are required to wear masks and gowns and gloves. You should have really consulted with your facility’s infection preventionist. You really should have.

Finally:

“Many of us in clinical health care have good reason to resent the obvious HIPAA violation that is taking place when health care workers are required to divulge whether or not they’ve been vaccinated against this year’s most likely influenza strains. Apparently, HIPAA only applies to some patients, not to all.”

What? Yeah, so her whole argument is that her private and protected medical information is being divulged to the public when she is required to either wear a badge that states she’s been vaccinated or wear a mask if she refuses to be vaccinated. You’ve probably seen this anti-vaccine argument before. It stems from the “sacred and impenetrable” relationship between a provider and their patient. However, there are two things at work here. Number one, she is not a patient. Whether or not she is vaccinated is not between her an a healthcare provider. It’s between her and her employer. And, number two, exclusions to HIPAA are allowed in matters of public health (as this so obviously is) and when the information needs to be divulged in order to operate the hospital in a better way. What do you think we, the public, think when we see someone with a cast over their arm? We think that they broke it. No HIPAA violation there. Why is it a HIPAA violation if we see your badge (if you got vaccinated) or your mask (if you’re not)?

If you feel like it, go read the article yourself, but, if you want to keep your sanity, stay away from the comments section. There’s even more anti-vaccine insanity there.

Another one for Dr. Peter Doshi

It’s been a while since I’ve written to you about Peter Doshi, PhD, the guy who thinks that the flu is not a big deal and who may very well be an HIV-AIDS denialist. He is probably not as prominent now in the anti-science media because he’s busy being the associate editor of the British Medical Journal and calling on drug companies to be more transparent with their data. (Big Pharma is the big fish everyone wants to take down nowadays.) Nevertheless, his work against the stockpile and use of neuraminidase inhibitors (NI) like oseltamivir (aka “Tamiflu”) is still out there. It still gets quoted.

The Lancet put out an article recently about the effectiveness of NIs and their effect on mortality in hospitalized patients. It is a meta analysis. This means that they took together a whole bunch of studies and looked at them in the aggregate. I don’t generally like these studies because it is easy to be biased in the analysis by discounting or ignoring some studies while favoring others. Still, when done well, these studies have more power because they’re looking at more subjects and more outcomes. This particular study took 78 studies done between 2009 and 2011 and looked at the outcomes for treatment while hospitalized. This is what they found:

“We included data for 29 234 patients from 78 studies of patients admitted to hospital between Jan 2, 2009, and March 14, 2011. Compared with no treatment, neuraminidase inhibitor treatment (irrespective of timing) was associated with a reduction in mortality risk (adjusted odds ratio [OR] 0·81; 95% CI 0·70—0·93; p=0·0024). Compared with later treatment, early treatment (within 2 days of symptom onset) was associated with a reduction in mortality risk (adjusted OR 0·48; 95% CI 0·41—0·56; p<0·0001). Early treatment versus no treatment was also associated with a reduction in mortality (adjusted OR 0·50; 95% CI 0·37—0·67; p<0·0001). These associations with reduced mortality risk were less pronounced and not significant in children. There was an increase in the mortality hazard rate with each day’s delay in initiation of treatment up to day 5 as compared with treatment initiated within 2 days of symptom onset (adjusted hazard ratio [HR 1·23] [95% CI 1·18—1·28]; p<0·0001 for the increasing HR with each day’s delay).”

In other words, giving an NI early in the course of the disease is associated with lower mortality, and giving it versus not giving it was also associated with a reduction in mortality risk. Note this: “These associations with reduced mortality risk were less pronounced and not significant in children.” That’s “clutch” right there and something that infectious disease doctors and pediatricians should keep in mind.

NIs are not a magic bullet against influenza. Nothing is, not even the influenza vaccine. But something is better than nothing, and something backed up by evidence is best. Contrary to Dr. Peter Doshi’s assertions about NIs, evidence keeps coming in that it is better to give them than to not give them, and that they actually reduce the risk of death from influenza in some groups. There is both observational and experimental evidence of this.

But you don’t have to just take my word for it.

More spitting on the graves of those who have died from influenza

He’s at it again. Lawrence Solomon has unleashed yet another heaping pile of cow dung onto his Huffington Post blog space. This time, he’s telling us that we “may” be better off without the flu vaccine. Why? What kind of fabulous insight “may” this non-epidemiologist, self-deluded fool have?

I wish I had more time. He begins: Continue reading

Influenza is here, it’s bad, and it’s killing people

Contrary to the opinions of people like Peter Doshi, PhD, and others that influenza is not that bad, influenza is pretty bad. Just ask the family of this woman in Texas how bad it is. Or ask the family of this girl. Influenza is being reported from all over the lower 48, Canada, and Mexico. Many public health agencies are now recommending the influenza vaccine as a countermeasure to the increase in cases. As an epidemiologist, I join other epidemiologists in saying that the vaccine is not a good countermeasure, and it shouldn’t be used as the lone countermeasure. It takes a while for it to confer immunity, so it may be too late now that the season is fully underway.

Continue reading