Vaccine Update for Healthcare Providers

On the Bookshelf - Archive

• "Proofiness: The Dark Arts of Mathematical Deception" Dec. 2011
• "Challenging Nature: The Clash Between Biotechnology and Spirituality" Nov. 2011
• "Nudge: Improving Decisions About Health, Wealth, and Happiness" Oct. 2011
• “House on Fire: The Fight to Eradicate Smallpox” Sept. 2011
• "The Emperor of All Maladies: A Biography of Cancer" August 2011
• "And the Band Played On" by Randy Shilts June 2011
• "The Best Kind of Different: Our Family’s Journey with Asperger’s Syndrome" May 2011
• Don’t Be Such A Scientist: Talking Substance in an Age of Style April 2011 >
• Vaccines and Your Child: Separating Fact from Fiction Mar. 2011
• The Panic Virus by Seth Mnookin Feb. 2011
• Deadly Choices: How the Anti-Vaccine Movement Threatens Us All Jan. 2011

"Proofiness: The Dark Arts of Mathematical Deception"

Paul A. Offit, Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

Charles Seife’s Proofiness: The Dark Arts of Mathematical Deception (New York: Viking, 2010) is a worthwhile read. Seife explores how statistics can and have been used to convey false information that encourage false beliefs.

One of Seife’s more interesting stories centers on Senator Joseph McCarthy’s campaign against supposed communists in the state department in the 1950s. McCarthy only gained credence for his false accusations after he gave the press a specific number of people: 57.

Seife also describes efforts by an Indiana state senator (Taylor Record) to round up the value of pi to 3.2 so that it would be more easily remembered.

Mostly, Seife focuses on how statistical manipulations have been used to influence political, medical and legal decisions. The book is of value in that in provides a larger context in which to place bogus ecological studies that have been used to denigrate the value of vaccines.

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"Challenging Nature: The Clash Between Biotechnology and Spirituality"

Paul A. Offit, Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

In the book, Challenging Nature: The Clash Between Biotechnology and Spirituality, Lee Silver, a molecular biologist at Princeton University, describes how science can be limited by cultural perceptions, especially views on religion and spirituality. Silver spends most of the book describing how our views of the origins of life affect our ability to take advantage of stem cells. His thought experiments will definitely challenge most people’s perceptions about how one defines a human being and what distinguishes humans from other animals.

In easy-to-understand prose, Silver also describes various touchstones of alternative medicine, specifically the origin of words like natural and organic as well as the history of therapies such as homeopathy. The book is a study in critical thinking and rationality.

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"Nudge: Improving Decisions About Health, Wealth, and Happiness"

Charlotte A. Moser, Assistant Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

"Nudge: Improving Decisions about Health, Wealth, and Happiness" is not a recently published title, but is well worth the read when thinking about decision-making, particularly as it relates to healthcare. Written by Richard H. Thaler and Cass R. Sunstein, it was both a New York Times Bestseller and The Economist’s Best Book of the Year following its publication in 2008.

In one of the last chapters of the book, Thaler and Sunstein provide a concise summary of their two major claims. “The first is that seemingly small features of social situations can have massive effects on people’s behavior; . . . The second claim is that libertarian paternalism is not an oxymoron. Choice architects can preserve freedom of choice while also nudging people in directions that will improve their lives.”

The authors set up their premise by defining the differences between the decision-making capacity of humans and so-called econs, the “textbook picture of humans who are equipped with the intelligence of Einstein, the memory of a computer, and the willpower of Mahatma Gandhi,” and then discuss various human tendencies, such as:

• Following the herd
• Choosing the default option
• Framing situations from personal points of reference

Paying attention to choice architecture, or giving a nudge, in settings where human tendencies may lead to poor decision-making is the proposed solution. However, the authors are attentive to the limits and ethical use of nudges throughout the discussion.

After setting up the framework, Thaler and Sunstein devote sections of the book to case studies in the areas of money, health and freedom. Discussions of saving for retirement, using credit and privatizing social security are the focus in the money section. The division of topics in the health and freedom sections is less clear as the health section discusses prescription drugs, organ donation and protecting the environment. While the freedom portion focuses on school choice, health insurance, and the institution of marriage as it relates to state and religion. In each case, the authors discuss possible nudges to improve existing systems.

Reading the book with vaccines in mind, I found the following points interesting to explore:

• People tend to follow the herd – Social influence, via nudging, can help when misconceptions spread. The authors cite several examples of social influence, including use of plastic bags when dog owners take their pets for a walk; increased risk of being overweight when your friends are overweight; and programming fads that arise because broadcasters mimic one another, such as the popularity of some reality television shows.
  
  Unfortunately, vaccines have been affected negatively by social influence, so we need to think about what can be done to leverage social influence for the benefit of vaccines.
• Framing is important – The way that problems are framed can determine choices because people do not tend to reframe the information before deciding. In the example cited, when retailers wanted to charge more to cover their fee for allowing payment by credit card, credit card companies pushed for language in the law that would make the credit price appear to be the normal price with a discount for paying cash rather than allowing retailers to advertise the cash price and add a surcharge for paying via credit.
  
  When thinking about vaccines, the better headline might read “Nine in 10 parents are getting their children immunized according to schedule” instead of “One in 10 parents are forgoing or delaying vaccines for their children.”
• Compliance – The authors described an experiment in Minnesota in which taxpayers were given four types of information. One group was told what their taxes were used for; a second group was threatened with information about what would happen if they didn’t pay their taxes. A third group was offered information about how to fill out their tax forms; and the last group was told that 90 percent of others in the state had already paid their taxes. The only group that showed a significant effect on their tax compliance was the fourth group.
  
  Compliance theory, as it relates to vaccines, would suggest that in the setting of a private practice or a school, simply sharing information about the number of families who have immunized may have a significant effect on the hold-outs.
• Path of least resistance – The authors provided several reasons why people tend to choose the path of least resistance, such as lack of inertia, a bias toward status quo, and mindless choosing, which they referred to as the “yeah, whatever” heuristic. Because of this tendency, many people choose the default option that is offered. The authors pointed out that the default choice tends to be reinforced when coupled with a suggestion, either explicit or implied, that it is the normal or recommended choice.
  
  In relation to vaccine mandates, evidence suggests that the choice to forgo immunizations should not be the easiest one. Wouldn’t the healthy nudge be that which makes being immunized the default? Some states have started to move in this direction by introducing educational requirements, annual discussions and a requirement for notarized signatures before accepting exemptions.
• Education – When employers educated their staff about retirement options, data suggested that despite increased intent to save more toward retirement, many employees never followed through once they left the seminar. For retirement contributions, the authors suggested a plan called “Save More Tomorrow” in which contributions automatically increased coincident with pay raises.
  
  When thinking about vaccines, choice architecture should consider ways to make the action naturally follow the education. For example, when a child is behind on vaccines, scheduling several appointments that offer a plan for catching up at the time of the initial discussion may increase follow through. Similarly, when a parent attends the required education before exempting their child, is there a possibility of immunizing that day or scheduling appointments before the parent leaves?

Helping families make good health decisions benefits everyone. In this book, Thaler and Sunstein offer ideas that suggest a libertarian paternalistic approach can provide families with choices while fulfilling the commitment to “first do no harm.”

"Nudge: Improving Decisions about Health, Wealth, and Happiness" is available from Amazon.com and Barnes and Noble.

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“House on Fire: The Fight to Eradicate Smallpox”

Charlotte A. Moser, Assistant Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

“You can smell smallpox before you enter the patient’s room, but it’s hard to describe. . . The odor, probably the result of decaying flesh from pustules, is reminiscent of the smell of a dead animal. On at least two occasions, smell alone alerted me to the presence of smallpox.”

And with this, William Foege, one of the central public health figures in the war against smallpox, begins his recently published book, “House on Fire: The Fight to Eradicate Smallpox,” providing readers with a unique front-seat perspective as the last few countries targeted a disease that today, most of us do not know.

Foege describes personal experiences that most readers would probably not consider a reasonable “part of the job description,” including arrest, illegal border crossings, breaking and entering, robbery, and evacuation and house arrest due to political unrest, providing a stunning account of what had to be done to complete the task at hand.

Having spent time in both Africa and India, Foege expertly describes the experiences and understanding that came from learning more about the biology of the virus, the cultures of the locales and the public health mechanisms employed.

As we move close to the eradication of yet another dreaded disease, polio, Foege’s insights take on particular gravitas. His accounts recall debate over the ability to eradicate smallpox, the unwavering commitment by workers who never lost sight of the goal and the necessity for an effective coalition.

Foege ends with the observation that he makes on each return trip to India: “. . .I have searched the faces of people on the street, looking for pockmarks. Soon I could find no pockmarked face under the age of 10, then 20, and now, no pockmarks are to be found on people under the age of 35.” What an awesome testament to the accomplishments of an army that worked for the good of humanity.

Foege’s book is available on Amazon and Barnes and Noble.

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"The Emperor of All Maladies: A Biography of Cancer"

Paul A. Offit, Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

In 2010, Siddartha Mukherjee published The Emperor of All Maladies: A Biography of Cancer , a book that later won the Pulitzer Prize. Mukherjee is a remarkable storyteller. Starting with the first chemotherapy (Sidney Farber’s aminopterin), to William Halsted’s disfiguring radical mastectomies, to cancer-causing radiation therapies, Mukherjee tells the grim tale of cancer’s collateral damage—normal tissues are sacrificed in the name of killing cancer cells.

Then the story shifts from non-specific to specific therapies, such as Tamoxifen, which targets estrogen-receptor positive breast cancers; Herceptin®, which targets the product of a specific oncogene (Her-2); and Gleevac®, which also targets a specific oncogene and has changed the face of chronic myelogenous leukemia — at one time, a death sentence.

Mukherjee tells his story in terms the general reader can easily understand. Anyone interested in knowing the history and the remarkable advancements of cancer therapies will enjoy this book.

The Emperor of All Maladies: A Biography of Cancer is available from amazon.com or Barnes & Noble.

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"And the Band Played On" by Randy Shilts

Charlotte A. Moser, Assistant Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

June 2011 marks 30 years since the first cases of HIV/AIDS were reported. If you were already practicing medicine, do you remember that time—the feelings, the fears, the vast unknown? If you were not yet practicing, what have you heard? To commemorate the anniversary, Dr. Thomas Frieden, director of the CDC, penned a media statement and a special section was added to the CDC website. We thought it appropriate to dust off Randy Shilts’ bestseller, And the Band Played On, for this month’s “On the Bookshelf” selection.

Randy Shilts was a reporter for the San Francisco Chronicle in the early 1980s when the first cases of HIV/AIDS were reported. His prologue begins “By October 2, 1985, the morning Rock Hudson died, the word was familiar to almost every household in the Western world. . . .But suddenly, in the summer of 1985, when a movie star was diagnosed with the disease and the newspapers couldn’t stop talking about it, the AIDS epidemic became palpable and the threat loomed everywhere. . . .The timing of this awareness, however, reflected the unalterable tragedy at the heart of the AIDS epidemic: By the time America paid attention to the disease, it was too late to do anything about it.” Although Shilts vastly underrated the work of scientists at the time, he effectively chronicled the beginnings of the epidemic in the United States.

The story begins on July 4, 1976 in New York and concludes in July 1985 in Los Angeles when the world found out about Rock Hudson’s diagnosis. During the nine-year period in between, Shilts introduces readers to all of the major players—patients, public health officials, doctors, scientists, politicians, activists and celebrities. Written according to the timeline and covering a broad array of settings, Shilts successfully weaves various threads to establish the complex picture of this public health story. Readers will find themselves at the intersection of the medical, social and political arenas as public health officials and providers grappled with establishing diagnoses, treatments and epidemiology; activists fought establishment, divides amongst their own and profiteers; and patients and families struggled with the illness and its attached stigma.

Whether to compare your own recollections or to better understand a period you did not witness, And the Band Played On will leave you contemplating not only the history, but the road we have since traveled.

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"The Best Kind of Different: Our Family’s Journey with Asperger’s Syndrome"

Charlotte A. Moser, Assistant Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

Written from a mom’s point-of-view, The Best Kind of Different: Our Family’s Journey with Asperger’s Syndrome chronicles one family’s experience with Asperger’s Syndrome. Shonda Schilling, wife of retired Major League Baseball pitcher Curt Schilling, makes it clear that this book is just that - a story of one family’s experience as she discusses Grant, their third child and his diagnosis of Asperger’s.

Against the backdrop of life as the family of a professional athlete, Shonda openly shares details of their experience before, during and after Grant’s diagnosis at the age of 7. Shonda discusses the struggles with discipline, effects on the rest of the family, and self-assessments of her own parenting skills before the diagnosis. She shares their feelings, reactions, and fears following the diagnosis and discusses what they have found that helped Grant, such as preparing for new situations in advance, giving only two choices at a time, instituting a reaction scale, and providing a routine among other things while acknowledging that these won’t work for everyone. In the context of a support group meeting, she mentions some hot button issues, such as vaccines as a cause (she doesn’t support the theory) and use of a special diet (didn’t try; mentions some drawbacks). But the focus of the book after Grant’s diagnosis is really on trying to learn about Asperger’s and trying to find a way to help Grant.

One of the most heartening aspects of the book is the positive tone. Although Shonda shares her struggles, she also celebrates Grant’s unique qualities, such as his compassion and his fearlessness about being different. She admits learning from him and embraces the mom she has become as a result of this experience, “As strange as it may sound, in every area of my life there are ways in which I have actually benefited from having a child with Asperger’s.”

For families just starting down the road with this diagnosis, this book will offer a shared understanding and, most importantly, a message of hope.

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Don’t Be Such A Scientist: Talking Substance in an Age of Style

Charlotte A. Moser, Assistant Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

With few exceptions, we can all become better communicators. Whether speaking to individuals or through mass communications, the way we look, the words we use, and the passion we feel will ultimately determine our success. Randy Olson’s book, Don’t Be Such A Scientist, makes readers think about various aspects of communication with a particular focus on penetrating public awareness and understanding related to scientific concepts.

Olson was a professor of marine biology when he decided to switch careers—heading to Hollywood to pursue filmmaking at the age of 38. The book begins with a very colorful tongue-lashing that he received from one of his early acting teachers. As Olson tells his story, he discusses the divide between the ways scientists communicate with those of Hollywood, which he calls “the most powerful, albeit hard to control, mass communication resource of today.”

In chapters with titles such as “Don’t Be Such a Poor Storyteller” and “Don’t Be So Unlikeable,” Olson uses concrete examples to offer suggestions for successful communication with the public. Given his scientific field of study, most examples deal with ocean conservation and environmental issues; however, his messages are applicable across the various disciplines of science and medicine. For example, he compares Al Gore’s successful movie, “An Inconvenient Truth” with “Too Hot to Handle,” a 2006 HBO documentary about global warming made in the same year and by the same executive producer. In several pages of discussion, Olson provides a thorough discussion of the content and styles of these two pieces concluding that although Gore’s movie had a few inaccuracies, its style and presentation allowed it to reach substantially greater audiences. While not promoting inaccuracy in the presentation of scientific issues, Olson does prod his readers to consider the importance of presentation style.

In the final chapter, “Be the Voice of Science,” Olson discusses Carl Sagan’s success in communicating science to the public, and the price he paid in the scientific community, being passed over when nominated for the National Academy of Science. However, he points out that the time in which we live requires more scientists to be bilingual; that is, speaking scientifically with our colleagues, but also with a voice understood by the public. And, he concludes by sharing the satisfaction that comes from connecting with broad audiences.

Olson’s book is available from both Amazon.com and Barnes and Noble.com.

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Vaccines and Your Child: Separating Fact from Fiction

Charlotte A. Moser, Assistant Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

We are pleased to announce the release of our new book for parents, “Vaccines and Your Child: Separating Fact from Fiction.”

• Table of Contents (scroll down after page opens)
• Read an Excerpt (scroll down after page opens)

Columbia University Press is offering a 30% discount on its website. Use Coupon Code “OFFVA” during checkout.

The book is also available at bookstores and online at Amazon and Barnes and Noble.

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The Panic Virus by Seth Mnookin

Paul A. Offit, MD, Director, Vaccine Education Center at The Children’s Hospital of Philadelphia

Seth Mnookin has written a wonderful book that examines the forces behind the fear that vaccines caused autism. Interviewing parents, public-health advocates, scientists, and anti-vaccine activists, Mnookin answers the important question, “How do we decide what is true?” This is a bigger book than its subject, helping us to understand how false claims survive in a media hungry for controversy, independent of whether the truth is sacrificed. A great read.

Mnookin, Seth. The Panic Virus: A True Story of Medicine, Science, and Fear. New York: Simon & Schuster, 2011.

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Deadly Choices: How the Anti-Vaccine Movement Threatens Us All

Charlotte A. Moser, Assistant Director, Vaccine Education Center at The Children’s Hospital of Philadelphia, Jan. 2011

Two books related to the anti-vaccine movement were recently released:

• Deadly Choices: How the Anti-Vaccine Movement Threatens Us All by Dr. Paul Offit - released on December 28 by Basic Books,
• The Panic Virus: A True Story of Medicine, Science and Fear by Seth Mnookin - released by Simon & Schuster on January 11.

Deadly Choices chronicles the development of the anti-vaccine movement in the U.S. and discusses its present-day format, spokespersons, and effects. Since the director of the Vaccine Education Center at The Children’s Hospital of Philadelphia, Dr. Paul Offit, is the author, we decided to interview him rather than review the book. We will review The Panic Virus in next month’s issue.

Interview with Paul Offit, MD

Why did you want to write this book?

I fear that we have passed a tipping point. Children in the United States are now once again suffering the diseases of their grandparents—diseases like whooping cough, measles, mumps, and bacterial meningitis. I wrote the book to sound the alarm. If we continue to let immunization rates slip, more children will suffer and die from these diseases.

What was the most surprising finding during your research for the book?

That the modern day anti-vaccine movement is nothing new. Anti-vaccine movements dating back to the 1800s in England used the same messaging and strategies, and shared many of the same fears as those of today.

What do you hope readers take away?

That we’re all in this together. That a choice not to get a vaccine is not only a choice that you make for yourself or your child, but for those who come in contact with you or your child. And there are about 500,000 people in the United States who can’t be vaccinated, who depend on those around them to be protected. We share an immunological commons.

Do you have any more books on the horizon?

Yes. I’m interested in writing a book about quackery in America, especially as it relates to children.

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