The CDC Moves to a More Rational COVID Vaccine Policy
So your HMO refused to pay for your CT scan?
Those of you who are regular readers know that for several years I have criticized the CDC’s recommendation of annual COVID boosters for everyone, especially for healthy young children, adolescents, and even young adults—irrespective of prior history of infection. Only 11% of children recommended to receive the vaccine this past fall received it, indicating that Americans across the political spectrum have decided that the CDC recommendation has no basis in scientific reality. The erosion of trust in Science is currently a hot topic for discussion, but is it really Science that a large chunk of the population distrusts, or is it the public institutions which are its forward facing messengers? There certainly is vaccine disinformation, both ignorant and malicious, and in order to counter that the government institutions of Public Health must CONSISTENTLY make their pronouncements logical, science based, consistent with common sense and politics free. If the CDC and other government authorities represent as scientific fact, that which is based on someone’s opinion, or guess—or worse obfuscates information deleterious to a perhaps well intentioned paternalistic goal—then a large part of the public will feel they have been lied to. If the average citizen feels they have been misled and given incorrect information about a certain vaccine once, can we really expect them to embrace future vaccine messaging? Enter the CDC’s ACIP (Advisory Committee on Immunization Practices) which met this week and is indicating that now 75% of their members feel they should change to recommending risk-based annual COVID vaccination, rather than the previous universal approach. Some will say, “They must have been pressured by RFK Jr.”. I’d like to believe these non-employee academic folks would welcome any opportunity to contradict Kennedy. Nothing at all fundamental has changed with COVID in the last year, so perhaps prior pressure to continue recommending yearly shots for toddlers has vanished. Whichever or neither is the case, I say it’s a step in the right direction, making CDC policy consonant with scientific data and the vast majority of American’s personal decision on the issue. I do recognize that “personal decision”, may be a trigger phrase for some since RFK Jr. used it in a vaccine discussion—but I’ve never accepted the notion that anyone has the right to control my use of the language, or in the case of absurd, mandated pronouns, the explicit nonuse.
While we are on the subject of vaccines, there is a significant change in the recommendation for Pneumococcal vaccine. Pneumococcus is one of the most common bacterial causes of outpatient pneumonia, estimated to cause 150,000 hospital admissions in the US every year. In addition to pneumonia this bug can cause very lethal invasive disease of the blood stream and vital organs, causing 3500 deaths a year. The number of deaths from pneumonia is less certain since many people with CAP (community acquired pneumonia) never receive a specific microbiologic diagnosis. Vaccines against the polysaccharide cell wall of the organism have been around since 1977, but more recent versions of the vaccine which are “conjugated” (the polysaccharide is linked to a protein which is more immunogenic) have greater efficacy The previous recommendation was to vaccinate everyone over 65 years of age, and people between 19-64 if they have specific health issues increasing their risk. (All children are advised vaccination, and this has dramatically reduced the incidence of invasive severe or fatal disease). The ACIP has now determined that adult vaccination should be a single dose of the conjugated vaccine at age 50. Unlike the COVID virus, this bacteria does not mutate quickly and the vaccine’s protection, which is in the 50-80% range, is very long lasting. If you are in that dinosaur demographic like me, go out and get a dose of the vaccine—even if you are not certain of your prior vaccination history—and save yourself some trouble.
The Texas centered measles outbreak continues to percolate along, now with over 700 cases and two deaths. The reason we have not had an explosive epidemic, like we used to see in the pre-vaccine era, comes down to the number of susceptible individuals. Epidemiologic models of infectious disease spread frequently use what is called a SIR model, where the population is divided into S (susceptible), I (infectious) and R (recovered, which are assumed to be at least temporarily immune). Nationwide the measles vaccine coverage is around 92%, 3% lower than the target of 95%, which is felt to effectively block community transmission. With a relatively low percentage of susceptible people we won’t have large state wide or a national epidemic, but given the extremely contagious nature of the virus and its airborne spread, it will continue slowly spread. In relatively isolated groups with homogeneous anti-vaccine views, such as we find now in two Texas counties, there will be rapidly spreading mini-epidemics. Apparently it takes more than a couple of dead toddlers to shake some people’s faith in their cult, or favorite cable news show.
As a society and individually, we don’t always make sound risk reward decisions, and often concentrate our attention on one health risk to the virtual exclusion of other greater issues. Take Influenza for example. For a non-epidemic year this was a pretty awful flu season (the first high severity season since 2017); the CDC estimates there have been 46,000,000 cases, almost 600,000 hospitalizations and 26,000 deaths so far this year. 188 children have died from influenza, including 20 during the past week, even while Influenza is winding down around the country. The vast majority of these pediatric deaths were unvaccinated. North Carolina has recorded just about as many deaths from flu (600) as from COVID. We have every right to be concerned about measles, and you can’t go a day without hearing it trumpeted in the media—but do you recall these Influenza statistics being shouted as a wake up call to get kids and older adults vaccinated? One more thing (as Steve Jobs used to say) about Influenza vaccine. A recent preprint on MedRXiv from the Cleveland clinic showed that vaccinated workers in their health care system were more likely to contract Influenza than non-vaccinated people. This of course was seized upon by the anti-vax elements as proof of the not only ineffectiveness, but the danger of the vaccine. Some critics of the study have focused on the wrong avenue to reveal the fallacies its conclusions. They note that this is a special population of mostly young healthy people, or the protection from vaccination wears off before the end of the flu season, or most prominently that the vaccine protects against more severe disease. That may all be true, but hardly addresses the the issue of why they found higher rates of Influenza in the vaccinated cohort, and hand waving like this is bound to just strengthen the arguments of the skeptics. The real issue in my opinion is that the authors neglected to consider the basic SIR model of disease spread in the structure of the study and interpretation of the results. If you get the flu one year, you will have a great deal of natural protection for the next several years, unless there is a major shift in the virus. This study make no allowance for the fact that the unvaccinated group, likely was unvaccinated in prior years, and had a much lower percentage of the S (susceptible) group. Also further confounding variables, such as mask use, and other behavioral risks are not controlled for. All science (at least “scientific studies”) are not created equal…there’s not even equity.
Polio virus is back in the news as reported in a study in MMWR. Not any polio virus but the vaccine derived type 2 (VDPV2), which has now been found in the waste water of cities in 5 European countries during surveillance from October through December, (Spain, Poland, Germany, Finland and the UK). Genetic analysis shows these viruses are directly linked to the strain which initially arose in Nigeria in 2020, and has continued to circulate there, causing the only cases of paralytic polio in the country. This vaccine derived virus has spread throughout West and North Africa, causing outbreaks of paralytic polio in 15 countries, and detection of virus in environmental samples in another 6. Further genetic analysis of mutation rate changes show that the virus was circulating outside Africa for at least a year before showing up in the European testing. The next time you are having a discussion with someone who believes that any vaccine approved by the government MUST be safe and effective, you can assume they are nearly as uninformed as the group that thinks MMR causes autism, and you might point them to this ongoing vaccine catastrophe.
Detection of Vaccine-Derived Poliovirus Type 2 in Wastewater — Five European Countries, September–December 2024. MMWR
Weekly / March 6, 2025 / 74(7);122–124
Monkeys aren’t the natural reservoir of Monkey Pox, they pick it up from some other mammalian host, and are subject to local outbreaks with significant mortality. (I am giving myself a pass on the mpox designation since every scientific article I read on the subject has the authors using mpox and following it with the traditional Monkey Pox; redundancy be damned). A recent article in Science details some very nice veterinary science detective work from a park in Ivory Coast. After observing one baby monkey with pox lesions which died a few days later, quickly followed by more fatalities in the troop, the scientists collected fecal samples from the monkeys and found that many had been infected with the virus, and some were not visibly symptomatic. They then tested fecal samples from a variety of small rodents and mammals that had been found dead or trapped. They found only one positive result in a dead rope squirrel. They then examined the feces of the mother of the first dead infant monkey and found rope squirrel DNA, indicating this monkey had eaten a rope squirrel. Not proof, but very suggestive evidence that these small mammals may be the natural reservoir. Ropes are not bad I’m told if you can’t find decent truffles or foie gras. The researchers find these animals are very illusive and hard to trap, so a representative sample to nail this down may take some more creative thinking.
CT scans came into clinical use while I was a medical student, and were quite a miraculous advance over the fairly barbaric pneumoencephalogram. For those of you who don’t recall the use of blood letting, leeches, reusable metallic antimony pills for constipation (yes they were retrieved after passage and used on the next patient), or mercury pills for syphilis—pneumoencephalography involved the injection of air, via a needle through the brain, into the ventricular system in the center of the brain. That allowed visualization of brain contours, and the ventricular system with standard X-rays. But CT scans deliver a relatively large dose of radiation. A single chest X-ray exposes you to about 0.1 mSv (millisievert), while a CT of the brain can deliver about 100 times that radiation, and other CT studies can be several times higher. Radiation of course is carcinogenic, and that’s around the amount of background radiation from cosmic rays you absorb every year. An April 14 paper in JAMA Network looks at how much future cancer risk may be associated with CT scans in the US. Using hospital and insurance data, they estimate 93 million scans were performed on 63 million people in 2023, and that radiation exposure will lead to the development of approximately 103,000 future cancers. The data they use to calculate risk comes from studies of Japanese patients exposed to radiation from the atomic bombs, because delivered dose can be calculated from the distance from ground zero; another natural experiment courtesy of some government decision (see my last post for a discussion of natural experiments and the Welsh National Health Service). Of course there are all sorts of confounding variables such as: the actual dose absorbed by the Japanese, various cultural and dietary confounders, plus the study includes all sorts of statistical analysis above my pay grade; but it is the most reliable data on radiation exposure and future cancer we have. My first reaction to this information was, “Good God, do we actually do that many CT scans, I wonder how many are actually necessary”. It would be nice to have some information on what percentage of this avalanche of scans reveal a truly significant finding, or how often they lead directly to a therapeutic change or altered outcome. Of course the risk of future cancer is greater in children, and it’s my impression that pediatricians are far more circumspect in the use of CT scans. In adults all bets are off, and I think it’s a complex mix of physician fear of litigation, patient expectations of what they feel is adequate investigation of their complaint, and physicians often giving little or no thought to ordering a test where a potential negative consequence is years in the future, and posses no litigation risk. So just maybe the greedy HMO which denied you a CT exam, did you a favor.
Projected Lifetime Cancer Risks From Current Computed Tomography Imaging
Rebecca Smith-Bindman, MD1,2,3; Philip W. Chu, MS1; Hana Azman Firdaus, MPH1; et alCarly Stewart, MHA1; Matthew Malekhedayat, BS1; Susan Alber, PhD4; Wesley E. Bolch, PhD5; Malini Mahendra, MD3,6; Amy Berrington de González, DPhil7; Diana L. Miglioretti, PhD4,8
Below we have Hogarth’s representation of a Marquise with his wife and teenage mistress encouraging the doctor to prescribe more mercury pills for their syphilis.
Thanks for your interest and attention. This week we are starting a pool were you can bet on how many giddy young girls (or older foxes) will offer to marry the handsome Luigi Mangione while in prison. You will get an extra bonus if you accurately predict the date on which Harvard will decide that 6 billion trumps (pun intended) their valued academic freedom. You may hit the like button, with assurance that the results will not be sent to either Kash Patel or Anthony Fauci. Happy Easter and Passover to all. I would be happy to hear from all the pediatricians and veterinarians!
Most informative substack available.