Doctors are "pushing vaccines"? Gee, you say that as though that were a bad thing!

I frequently point out how antivaccine activists really, really don’t want to admit that they are, in fact, antivaccine, so frequently, in fact, that I have a series that I call The annals of “I’m not antivaccine.” It’s already up to part 21. It could easily be up to part 51, or 101, or even 1,001. The only reason it isn’t is because I don’t want to devote this blog to nothing other than how antivaccine activists who deny they’re antivaccine routinely inadvertently reveal the truth.

If there’s one area in which antivaccinationists reveal themselves to be antivaccine, it’s in their reaction to any sort of efforts to encourage vaccination. Given how vaccination protects populations from vaccine-preventable diseases, it’s important to maintain high levels of vaccination. The reason, of course, is that a high percentage of any given population (usually at least 90%) needs to be protected from any given disease to achieve herd immunity to that disease. Basically, herd immunity (sometimes also called “community immunity” in deference to people who don’t like the connotation of the word “herd”) is general immunity to a pathogen in a population based on acquired immunity to it by a large proportion of that population. Basically, when a “critical mass” of a population that depends on the contagiousness of the pathogen and the efficacy of the vaccine is vaccinated, even unvaccinated members of that population are protected from the pathogen vaccinated against. Basically, when a high proportion of a population is immune to a pathogen, its chain of transmission is broken, a concept illustrated below:

Community immunity

Thus, it is very desirable to vaccinate as large a proportion of the population as possible. How to achieve that? In the US, there are school vaccine mandates, which require children to have had certain vaccinations as a precondition to entering schools. However, it’s not just the “stick” that is used to achieve vaccine uptake high enough for herd immunity, in which the children of those who refuse to vaccinated can be denied something. There are also multiple points in the system where “carrots” can be used as well, such as incentives, and multiple points where persuasion in the form of public relations and advertising can also be effective.

This drives antivaccinationists crazy.

Indeed, one way to identify antivaccine activists is by how they react to such campaigns. Take, for instance, a recent string of posts about the CDC AFIX program. AFIX stands for (Assessment, Feedback, Incentives, and eXchange). It’s described on the CDC website thusly:

AFIX is a quality improvement program used by awardees to raise immunization coverage levels, reduce missed opportunities to vaccinate, and improve standards of practices at the provider level. The acronym for this four-part dynamic strategy stands for

  1. Assessment of the healthcare provider’s vaccination coverage levels and immunization practices.
  2. Feedback of results to the provider along with recommended quality improvement strategies to improve processes, immunization practices, and coverage levels.
  3. Incentives to recognize and reward improved performance.
  4. eXchange of information with providers to follow up on their progress towards quality improvement in immunization services and improvement in immunization coverage levels.

Having been a co-director of a statewide collaborative quality improvement program designed to improve the quality of brast cancer care in my state, I recognize this as a rather unremarkable and common strategy to improve quality of care, a typical quality improvement cycle, in which iterative improvements are made though these very strategies. Indeed, the CDC provides a 78-page book of standards for providers to implement AFIX. Not surprisingly, it begins with a discussion of what continuous quality improvement (CQI) is and how AFIX is a CQI.

Not surprisingly, antivaccinationists do not like AFIX at all. No, not at all. For instance, Rishma Parpia over at The Vaccine Reaction, the house organ of the antivaccine group National Vaccine Information Center (NVIC) is outraged that doctors are “incentivized by CDC to increase vaccine coverage.” (The horror. The horror.) Note how Parpia characterizes AFIX right off the bat:

Many people have encountered going to their physician’s office or their child’s pediatrician’s office and being coerced into “getting up-to-date with their shots.” This is not a rare or random occurrence. There is a method and approach that federal health officials expect health care providers to enforce in order to ensure that vaccination coverage goals are met at the local level.

Not exactly. Like all CQIs, AFIX is a voluntary program. However, if you agree to be part of it, then, yes, certain standards are encouraged. That’s how CQIs work. What seems to bother her the most about the program is, of course, the database that is maintained to assist in the improvement of vaccination rates. This database is portrayed as being particularly Orwellian:

This indicates that a centralized national electronic medical/vaccine record keeping system is being operated by the CDC and that a patient’s medical records, including vaccination history, is now or will be readily available to all health care providers, hospitals, federal and state government agencies, schools, etc. This has serious implications for medical privacy, exercise of medical informed consent rights and the potential for abuse of personal information by social service and law enforcement agencies, as well as doctors discriminating against children and adults who have not received every federally recommended vaccine.

Of course, given that, unlike several industrialized countries, the US does not have a national health system, one of the most vexing problems in CQIs, regardless of what specific quality measures are being addressed, is how to track patients who receive care at more than one facility or to track patients who move. In my CQI, if a patient left the system (i.e., left the state or transferred care to a hospital outside of the CQI), it was a problem and efforts were made to find out what happened to those patients. Those efforts, as you might imagine, weren’t always successful. If you are a health investigator in, for instance, Denmark, you would have access to the Danish National Patient Register, which contains health records for everyone in Denmark. We don’t have anything like that. Consequently, it is not surprising that the CDC would want to try to create a record of vaccine coverage to be used by providers who are part of AFIX. After all, you can’t improve what you can’t measure

I also can’t help but note that some states do in essence the same thing. Michigan, for instance, there is the Michigan Care Improvement Registry (MCIR). Basically, providers are required to report childhood immunizations to MICR within 72 hours of administration. Any physician or the local health department can print an Official State of Michigan Immunization Record at any time. Ironically, there is a safety aspect to this that even antivaccinationists should approve of, that of preventing duplicate vaccinations. If, for instance, a parent loses a child’s vaccination record, the school can be provided with the child’s immunization record to satisfy school vaccine mandate requirements. Of course, the main drawback of this system is that it is only useful in the State of Michigan. If a child moves to another state; it ceases to be as useful.

Parpia also notes that the AFIX program tries to address “missed opportunities” to vaccinate. Specifically, it encourages providers to send reminders and recall messages to patients and abide by standing orders that allow vaccination without the direct involvement of a physician at the time of immunization, noting:

It is important to understand the aggressive strategies that health care providers are being taught to use to increase use of all federally recommended vaccines. Regardless of what vaccination or other health care choices you make for yourself or your family, it is so important to take the time to become fully informed about all the risks involved and defend your right to make a voluntary decision. It is your basic human right.

Of course, nothing in AFIX does anything to take away any rights of patients to refuse vaccines. For one thing, contrary to what antivaccinationists would lead you to believe, no physician, nurse, or other provider can force an adult to take any vaccination. They can’t “force” children to be vaccinated, either. However, if a child isn’t vaccinated, school vaccine mandates will mean that there is a consequence to that decision not to vaccinate the child, and that consequence will be that the child will not be permitted to enroll in school and day care, where unvaccinated children can degrade herd immunity and make outbreaks of vaccine-preventable diseases more likely.

Not surprisingly, uber-quack Dr. Joe Mercola doesn’t like AFIX either and characterizes it as providers being offered “bribes” to recommend vaccines. In particular, he compares the incentive program to encourage increases in vaccine uptake to lobbyist Jack Abramoff, who at the center of a massive corruption scandal a few years back and ultimately sent to prison for three years. Not surprisingly, he blames passage of the law that established AFIX on—you guessed it—big pharma. The goal? To make money by encouraging vaccination:

It’s important to understand that the foundation of corruption is all about bribery, and bribery involves giving a gift with monetary value to somebody, who makes a decision on behalf of the public. Certainly, doctors have tremendous influence over their patients, and providing gifts/incentives to doctors to sell more vaccines is not really in the public’s best interest… Health factors such as individual biological susceptibility to vaccine damage is completely ignored in this scenario—the only thing that counts as “good” is increasing overall vaccine use by all patients.

Gee, Mr. Mercola, you say that as though increasing overall vaccine use by patients were a bad thing. It’s not. In general, it actually is good thing. The only way you can view increasing vaccination rates as a bad thing is if you believe that vaccines cause more harm than good, or at least if you believe that the risk-benefit ratio for vaccines is not nearly as in favor of vaccinating as it is. In other words, you have to buy into antivaccine misinformation that vaccines cause autism and that severe vaccine reactions are common as opposed to the true case, that they are very rare. Mercola would characterize incentivizing doctors to vaccinate as a form of “corruption” designed to benefit big pharma rather than patients. It’s not. For one thing, it’s public knowledge. (Indeed, it’s right there all over the CDC website.) For another thing, in this case (as is the case for all CQIs), physicians are being incentivized to live up to the standard of care, to do, in essence, what they know they should be doing anyway. That’s how CQIs are supposed to work, and it benefits patients when they do work that way. It would be lovely if no such incentives were ever required, but, human nature being what it is and physicians being human beings, sometimes a little nudge is required.

It’s not just doctors, either. There are incentive programs offered by the government and insurance companies to parents of patients to encourage vaccination. Not surprisingly, antivaccinationists view these sorts of programs as evil as well. For instance, the Orwellian-named antivaccine website VacTruth recently posted an article entitled Back to School Shots: How Your Child is Being Programmed. Before I go on, I can’t help but note that any time you see a group that includes the word “Truth” in its name, especially with a capital T emphasized the way VacTruth emphasizes it, there is a high probability that it is peddling bullshit. In any case, VacTruth sees these incentive programs as pure evil and mocks programs offered by some states, based on the recommendation of the CDC and the Healthy People 2020 campaign to consider “client or family incentive rewards, used alone or in combination with additional interventions” to increase vaccination rates:

In southeastern Idaho, the public health department is offering Kindle Fire tablets in monthly drawings for children who receive vaccines at special clinics. They are offering a total of 24 tablet devices each month to entice children and parents into accepting vaccines.

Their state health department claims that “legally, in order to enter kindergarten, children are required to have five DTaP, two MMR, four Polio, three Hepatitis B, two Varicella (Chickenpox), and two Hepatitis A” vaccinations.

However, the press release fails to disclose that in Idaho, parents may file a medical, philosophical, or religious exemption from those vaccines on behalf of their children.

Why should Idaho have included that in its press release? This is an incentive program, not a mandate. In any case, apparently a fair number of states have similar programs. In Kansas, for instance:

In Kansas, health departments in 105 counties have recently offered an outreach incentive program called “Immunize and Win a Prize,” targeting children under the age of two. Children must complete 19 vaccine doses before their second birthday in order for their parents to be eligible to win a prize, including a $200 or $300 utility bill payment at each of 380 participating providers and 300 smaller prizes. The program also provides petty incentives like sippy cups and diaper wipes. [9, 10]

This program was instituted in 2003 and all children are now eligible to participate, not just children who participate in Medicaid programs. Since its 2003 inception, immunization rates in Kansas have risen from 49 percent to 87 percent in 2010. In some counties, immunization rates have even doubled.

Again: Gee, you say that as though it were a bad thing. One wonders if the author of this post is upset because of the incentive programs or more upset that this particular incentive program appears to have worked quite well.

VacTruth is also upset that insurance companies would offer incentives for vaccination. It doesn’t seem to occur to them why insurance companies might do that. (Hint: It’s not because they are in the pockets of big pharma.) Think about it. Administering vaccines costs insurance companies money. Yet insurance companies are not only encouraging vaccination but offering incentives to both parents and physicians to vaccinate; i.e., paying money in order to spend money on vaccinations. Why would insurance companies do that? The answer is obvious: In the long run it saves them money by preventing diseases that much more expensive to treat than to prevent. Also think of it this way. If vaccines really did cause autism or severe vaccine reactions were as incredibly common as the clueless wonders at VacTruth would lead you to believe, insurance companies would be discouraging vaccination because in the long run it would cost them a lot more money to treat autism and all the severe “vaccine injury” resulting in long term disability from it. Yet insurance companies encourage vaccination. As I like to say: Follow the money. Vaccination saves lives and prevents serious illness, which insurance companies have quite correctly judged to result in overall savings.

The bottom line is simple. If you’re antivaccine, any effort whatsoever to promote vaccination is “pushing” vaccines. If that effort involves school vaccine mandates or any other sort of government requirement, to antivaccine activists it’s an unacceptable infringement on “parental rights” and personal freedom. If, on the other hand, that effort involves any sort of incentivization, be it of parents, patients, or doctors, even with trivial gifts or rewards, it is inherently something shameful, “corrupt,” and somehow dishonest. While it’s possible for incentivization to be misused, there is no evidence that this is the case for AFIX and other programs designed to improve vaccine uptake, which, when you come right down to it, encourage physicians and patients do do what’s best for patients.