State Vaccination Exemption Policy Makes A Difference

Mother Jones has just run a very nice analysis of recent years' research on state laws governing non-medical exemption from childhood vaccines. It turns out that if a state makes it very easy for parents to exempt their children from recommended school vaccinations for non-medical reasons, lots of parents will exempt their children. This causes loss of herd immunity, and children die of childhood diseases that haven't been common for decades. And when one state (Washington) tightened up its rules by requiring a doctor's signature for exempting children from vaccination, exemption rates fell by 40%.

Meanwhile, cases of measles are on the rise in California--more than half of them involving children who were intentionally not vaccinated.

Medicaid Sterilization Policy Causes Unwanted Pregnancies

Here's an interesting article from the New England Journal of Medicine on Medicaid's policy regarding voluntary tubal ligation. Borrero et al. claim that Medicaid policy is preventing poor women who desire sterilization from receiving the procedure, resulting in tens of thousands of unintended pregnancies annually.

A surprising number of women desire tubal ligation immediately after giving birth; the procedure is conveniently done while they're still in the delivery room. More than 70% of sterilization procedures done within two years after delivery are in fact done in the immediate postpartum period.

Because of our nation's appalling experience with coercive and non-consensual sterilization of minority and poor women in the mid-20th century, however, the US government in the 1970s developed regulations designed to protect vulnerable women. Among these was a requirement for Medicaid patients of a 30-day waiting period between informed consent to sterilization and the actual sterilization procedure.

This well-intentioned regulation, unchanged since 1978, is today preventing women from receiving sterilizations that they actually desire. Some women request sterilization too late in pregnancy to fulfill the 30-day Medicaid waiting period; some are denied sterilization because they do not have their consent form present at the time of delivery; some give birth early, before the mandatory waiting period elapses.

The results of denial of sterilization services to Medicaid patients are very real. Almost half of women who are denied tubal ligation get pregnant within one year after delivery. The authors have found that "Medicaid-policy–related barriers lead to approximately 62,000 unfulfilled requests for postpartum sterilization annually, resulting in an estimated 10,000 abortions and 19,000 unintended births in the subsequent year...."

Both the financial and the emotional costs of these unintended pregnancies are very high. The authors estimate the cost to American taxpayers of the pregnancies at over $215 million annually. And wealthier, privately-insured women face no such policy barriers to receiving the sterilization procedure they desire. It might be time to revisit a policy that is harming the people it was originally implemented to protect.

Science Humor, Chocolate-Faced Nobel Winners Edition

This article from New England Journal of Medicine conclusively proves, sorta, that countries that consume more chocolate per capita produce more Nobel Prize winners. Enjoy!

Bad News on Vaccinations

This letter to the New England Journal of Medicine reports an increase in the rate of non-medical exemptions from the childhood vaccinations generally required by state law. (Non-medical exemptions are permitted in 48 of the 50 United States.) States that allow "philosophical," as opposed to only "religious," exemptions to mandated childhood vaccinations, had higher rates of exemption, as did states with "easier" opt-out provisions. Easy opt-out states allow parents to opt out of the vaccination requirement by filling out a standardized form supplied by the school; harder opt-out provisions require an original and/or notarized letter from the parent, or a form obtainable only from the state health department.

For whatever reason--but certainly including unscientific vaccine/autism fear-mongering--there has been a dramatic decline in US parents' willingness to vaccinate their children. The result has been the return of deadly childhood diseases including pertussis, whooping cough and measles. Vaccination is among the most effective public health measures. Certainly, states should make it harder for parents to opt out of vaccination programs for non-medical reasons. But rates of opt-out are on the rise even in "difficult" opt-out states, and there is some evidence that when states make it hard to opt out of vaccination for non-medical reasons, parents respond by pressuring doctors to write them bogus "medical" excuses.

The root of the problem seems to be that vaccines are victims of their own success. Most people haven't seen the effects of the awful childhood diseases that vaccines have been so effective at eradicating. But they've heard about vaccine reactions, and have heard all the unsubstantiated--or downright fraudulent--claims about vaccines and autism. How many kids will have to suffer or die with whooping cough or measles or pertussis before the public can be persuaded to trust in some of the most reliable science in all of public health?

Physician Interpretation of Industry Funding

According to this article in the current New England Journal of Medicine, physicians are more apt to prescribe drugs supported by studies they perceive as rigorous, than those supported by studies perceived as less rigorous. More interestingly, though, physicians downgrade their perception of the rigor of a study, their confidence in its results, and their willingness to prescribe the studied drug, when the study discloses that it was industry-sponsored. Physicians surveyed were twice as willing to prescribe a drug supported by an NIH study than one supported by an industry-sponsored study.

In general I greet this as good news. Industry sponsorship injects bias into the literature in many ways: via unconscious biasing of sponsored researchers, via careful selection of the kinds of studies sponsored (e.g., avoidance of head-to-head drug comparisons that have any chance of turning out badly), and even (in a few documented cases) via the burial or abandonment of sponsored studies that don't work out. So it's fine if physicians greet industry-sponsored trials with some skepticism.

Two worries, though: first, there can be too much of a good thing. After all, if a company develops a drug that really works, it will want to sponsor studies to prove that fact; and too much skepticism of positive results could end up hurting patients. Second, if industry sponsorship gives rise to skepticism, then there's an incentive to bury the fact of industry sponsorship via ghost authorship or other means.

Study registers, publication of negative results, rigorous authorship standards, rules for disclosure of funding sources and of conflicting interests, public funding for independent research: these can all help.

But the facts are 1) that we rely on private, profit-motivated research to find our new drugs; 2) that such research has historically done an excellent job in discovering and publicizing useful new drugs; and 3) that the very same motives that drive the industry to do a good job in discovering and publicizing useful new drugs are those that drive it to pollute and bias the literature. So there will be no easy answers.