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Vaccines

Why Do So Many Vaccinated People Get the Mumps During an Outbreak?

By February 21, 2017 2 Comments
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As of just a few days ago, over 400 confirmed and probable cases of mumps have been diagnosed in Washington state. To put this in perspective, in a full year the entire United States can expect to see roughly the same number of cases. We’re not even two months into 2017 yet.

Since the mumps vaccination program began in 1967 the United States has seen about 440 cases per year. Since 2005, however, there have been 6 years with over a thousand reported cases. Last year, in fact, there were 5,311 cases of mumps, about half of which came out of Arkansas alone. That outbreak started in August and peaked at 50 cases per day. In 2006, about 6,500 college students throughout the midwest were infected. 2009 and 2010 also saw large numbers of cases in New York and New Jersey, where about 3,000 students were infected. In 2014, there were several hundred cases in Columbus, Ohio, up from their typical yearly average of one.

Usually when there’s an outbreak of a vaccine preventable disease, the majority of cases are attributable to individuals that are unvaccinated or under vaccinated. But with the mumps, we’re seeing a much larger proportion of the cases from individuals whose vaccines are up to date. Why is this happening, why are the mumps on the rise, and why do we care about the mumps anyway? To answer all of those questions, we first need to answer what the mumps is and how it spreads.

What is mumps?
The mumps is a viral infection that only occurs in humans. Lucky us. Like the measles, it is a Paramyxovirus. Paramyxoviruses are a family of particularly nasty viruses. They include respiratory syncytial virus (RSV), which is the most common reason that children under two are admitted to the hospital, and parainfluenza, the virus responsible for most cases of croup. While only humans get the mumps, other animals are vulnerable to Paramyxoviruses, including dogs (canine distemper virus) and dolphins (morbillivirus). In short, Paramyxoviruses are no fun no matter what species you are.

The mumps is also like measles in that it is extremely infectious and easily, if not literally, jumps from susceptible host to susceptible host. It doesn’t care about the age, ethnicity, sex or religion of the host either. The most important factor in transmission, other than susceptibility, is proximity of potential hosts, which is why so many outbreaks have occurred where people are in close quarters: schools, camps, sports teams and military bases.

The virus is suspended in respiratory droplets but can also be transmitted by direct contact with infected patients or objects. Once in the body, it tends to incubate for a couple of weeks prior to causing symptoms but viral shedding takes place anywhere from a few days before symptoms to several days after they occur.

Those unlucky enough to develop classic mumps will still have nonspecific cold or flu-like symptoms initially, such as fever, malaise, significant appetite loss, and body aches. They will then develop inflammation of the parotid glands, which are salivary glands located on the cheeks over the angle of the jaw, within a couple of days. The degree of swelling can be substantial, very painful, and can last for up to 10 days.

One of the most famous photos of the mumps recently is of Pittsburgh Penguins star Sidney Crosby giving an interview before he received his mumps diagnosis. The virus spread through the NHL like wildfire that year, leaving dozens of players sidelined with the virus.

Unfortunately, mumps is known for more than simply self-limited involvement of the parotid glands. In postpubertal males, inflammation can occur in the testicles. This is known as orchitis, and occurs in roughly one out of three older boys, and can cause atrophy and infertility. Older girls can develop inflammation of the ovaries, but this isn’t nearly as common.

The most common complication after parotid swelling is meningitis. Thankfully this form of viral meningitis tends to be mild and doesn’t cause long-term injury. But in a small percentage of patients it can be extremely painful. A more diffuse inflammation of the brain itself, known as encephalitis, can also occur. It is rare, about one out of every 6,000 cases, and also generally doesn’t cause long term difficulties, but it is more likely to cause severe symptoms such as altered mental status, seizures, and muscle weakness or temporary paralysis.

Mumps is also associated with hearing loss that in some cases is permanent. Other rare but potential complications include Guillain-Barre syndrome, facial palsy, pancreatitis, and even a potentially fatal inflammation of the heart. Unlike rubella, mumps has not been linked to birth defects when a pregnant woman is infected, although as I mentioned before in some cases it can lead to sterility in men when the mumps are contracted as an adult.

In a small but significant percentage of infected individuals, as much as 15 to 20% in fact, there are no obvious symptoms. Some will only suffer nonspecific complaints that are similar to the common cold. But these lucky folks can still serve as a source capable of spreading the virus to other susceptible hosts.

How is mumps treated?
There is no treatment for mumps that is specific to the infection. Just like many other miserable viruses, there’s no treatment that can shorten the duration of the illness, but we can offer supportive care. The general approach is medications to target pain, fever, and inflammation. Ibuprofen is a good choice that targets all three concerns. Non-pharmaceutical interventions are equally important and can include warm compresses, ice, elevation of a swollen scrotum, and good old-fashioned TLC. It is rarely necessary for a patient to be admitted to a hospital, but not unheard of with involvement of the brain or pancreas.

Preventing spread of the infection to susceptible hosts is an extremely important aspect of mumps management. The most effective step in prevention is vaccination.  The mumps vaccine is part of a combination shot called MMR or sometimes MMRV (these are two different vaccines that provide protection against the measles, mumps and rubella, although one also protects against varicella (also known as the chicken pox)). The MMR/MMRV vaccine is a part of the recommended immunization series for all children without medical contraindications, with doses at 12 to 15 months and 4 to 6 years considered adequate. A third dose has shown some potential efficacy in helping to stop spread during an outbreak.

If an individual has a confirmed or suspected case of the mumps we generally recommend patient isolation for up to five days after symptoms first begin. We also recommend vaccinating anyone who might be at risk, although this may not prevent illness in those who have already been exposed.

Why are so many cases occurring in vaccinated individuals?
I said before that the mumps are a Paramyxovirus, which is in part why the mumps vaccine is given in the same combined shot as the measles vaccine, which is also a Paramyxovirus. The MMR/MMRV  consists of a weakened live virus and unfortunately, the mumps vaccine isn’t as good as its measles counterpart. Even with a second dose upon entering school there is only 80-90% effectiveness. In comparison, two doses of the measles vaccine component of the MMR/MMRV is 99% effective at conferring immunity.

To really quantify what that 80-90% efficacy looks like for the mumps vaccine you need to look at what’s called the attack rate. That sounds like something out of Game of Thrones, but I promise it is a legitimate scientific term. In epidemiology, the attack rate of a virus refers to the percentage of people within a population that contract a circulating virus. We know from studies done both during and after the most recent mumps outbreaks that the attack rate for the virus among individuals with two confirmed doses of the MMR vaccine is about 4% and anywhere from 25-43% for those who are unvaccinated. That’s a pretty big risk reduction, no matter how you look at it.

The other issue that skews the numbers on the mumps outbreaks is sheer volume. In recent and current outbreaks of mumps in the United States, most people exposed to the virus are vaccinated. The number of exposed people likely numbers in the many thousands. Only a small percentage of those vaccinated and exposed individuals are becoming ill, but 4% of thousands of people adds up. If this were an unvaccinated population, the number of cases would be significantly larger.

In order for herd immunity to play a role in preventing outbreaks of mumps, 92% of exposed individuals would need to be immune. But due to the lower efficacy rate of the mumps vaccine, we aren’t going to get “perfect” herd immunity even if 100% of people were vaccinated, which is why we’ve seen about 440 cases of the mumps per year since the vaccine was introduced. Until we have a better mumps vaccine, we won’t be able to eliminate the virus like we have smallpox or polio. By the way, those 440 cases a year are almost to the number we would expect, statistically speaking, if there was approximate herd immunity based on the attack rate.

So if the numbers for the last several decades have been almost spot-on what we would expect, why is there now a surge in mumps cases? As we’ve seen over the last 15 years there have been significant declines in vaccination coverage in specific geographic pockets as well as socio-economic groups, which has presented more opportunities for the virus to get a foothold, even if national vaccination rates remain high.  Those pockets provide more opportunities for exposure, for everyone else, including those who are vaccinated.

Finally, these outbreaks have provided concrete evidence of what we’ve suspected for a number of years: the efficacy of the MMR vaccine starts to wane after 10-15 years. This has helped build the case for the need for a third dose of the MMR/MMRV vaccine. The third recommended dose isn’t on the CDC schedule for adults yet, but if you have concerns about yourself or your college-aged child, it’s something you might want to discuss with your doctor.

So what’s the short version? The mumps isn’t the most serious vaccine preventable disease, but it is highly contagious and it’s pretty miserable. The mumps portion of the MMR vaccine isn’t as effective as the measles portion, but it still significantly cuts your child’s risk of contracting the disease. The vaccine is performing as well in the real world as we would expect it to in statistical models, and the volume of individuals fully vaccinated and exposed to the virus skews the data. Also, if it’s been more than 10-15 years since you or your child has last had their MMR or MMRV, you might want to talk to your doctor about receiving a third dose.

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Categories: Infectious Disease + Vaccines

What Is Thimerosal and Why Are Some People Worried About it?

By April 14, 2016 3 Comments
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“I don’t wanna put mercury in my baby, Doc; it’s poison.”  After Robert DeNiro’s anti-vaccination massive misstep Tuesday, I’m yet again, dreading hearing these words.

This is where, as a pediatrician, I grit my teeth (sorry, dentists).  I know that when I parent tells me this,  that science has lost another battle with fear in the race to inform families first. Since the race has been lost, I know I’m going to have to work from behind to get this child protected from deadly diseases.

There will likely be a lot of questions for me.  Questions based on faulty premises and that question my integrity as a doctor, as a dad and as a person.  I will put my pride aside and try to help these parents make the right choice for their kid.

I will explain that thimerosal is not mercury (although it contains very small amounts of it).

I will explain that even though there was no evidence that thimerosal was harmful, that it was removed from early childhood vaccines in 2001.

I will try to communicate with evidence-based information.

I will bring up the fact that Andy Wakefield, the man behind the current anti-vaccine movement and the movement has had his medical license revoked after the General Medical Council in the UK found he committed professional misconduct and acted dishonestly and irresponsibly. I will remind them that they don’t know many people that sleep in iron lungs because of Salk’s polio vaccine.

Reluctantly, I may even have to go into my personal life and divulge that my entire household (my wife, two girls and I) is fully vaccinated. These things may or may not sway the family.The conversation may end in an awkward stalemate. There could be a conversion that occurs over months.

I hope not, though, “because deadly diseases ain’t waitin’ on you to decide.” I get colloquial once we’re all good friends.

Sometimes people change their hearts and minds right away when I reassure them; those conversations are more fun, but I am usually wary of the spurious information that is just outside the hospital doors, or sometimes in the room with me on their smart phones.  I know once I’m done talking to them, there’s a whole lot of noise outside waiting to undo what I just did.

Robert DeNiro Appeared on NBC's Today Show on Tuesday

Robert De Niro Appeared on NBC’s Today Show on Tuesday

Like Tuesday, during The Interview Heard Around the Internet, when one of the greatest (the greatest?) screen actors of all time went full anti-science on the Today Show. Robert DeNiro, in explaining why he regrets the pulling of the movie “Vaxxed: from cover-up to catastrophe” from his Tribeca Film Festival, made some dangerously inaccurate statements about vaccines and autism.

In case you missed the discussions from a few weeks ago, here’s the skinny: Big-time festival announces the screening of a pro-disease (or, anti-vaccination) motion picture, the scientific community loses our collective mind and lets them know it’s a dangerous choice, Big-time festival pulls the movie, anti-vaxxers go up in arms. The science community was FINE with this result (you know, the support of actual scientific fact), even tentatively giddy.

Bobby D pulled no punches in his NBC interview, citing most of the tried-and-true tropes of the antivax movement: he stated that vaccine science is not “settled,” claimed “overnight” changes in children after immunizations, talked about mercury in vaccines and even gave the ol’ “I’m not anti-vaccine” speech, which is pretty much only said by people that are.

I’d love to make a reference to the classic “Just when I thought I was out, they pull me back in”… but that was Pacino’s line.

As a parent, if someone told you the nonsense that De Niro spouted on the Today Show, it would sound terrifying. No one wants to cause harm to their own child (or someone else’s). As a doctor I can tell you I’ve dedicated my life to helping parents keep their kids safe.  I don’t want to see your kid hurt either.  So let me break down De Niro’s claims starting with thimerosal.

The reality is that if De Niro got his information from better sources and actually talked to real scientists he’d know that a lot of what he just said isn’t true. He’d know that thimerosal hasn’t been in early childhood vaccines for 15 years, and he’d know that it was never in the MMR vaccine, the one that his boy Andy Wakefield falsely claims causes autism.

He’d also know that thimerosal is a mercury-based substance used in multi-dose vials of vaccines as preservative. It kills bacteria and prevents the growth of fungus in the vial, to help keep it sterile and safe for injection. It’s also a substance found in tattoo ink in concentrations thousands of times higher than what is found in vaccines. The compound breaks down into ethylmercury, half of which is broken down and rendered “ineffective” by the body in about a week. Then, we poop it out!

He’d know that in term of quantities, the amount of mercury given in a yearly flu vaccine is 25 micrograms (mu). The amount needed to kill 50% of living organisms (LD50) is 98 milligrams (mg) per kilogram (kg) of body weight. Remember, 1 milligram is equivalent to 1,000 micograms – so this means that, for a 10 kilogram (about 22 pound) child to have life-threatening effects, the child would need to have 980,000 micrograms of mercury. At one time.

He’d contrast this with methylmercury, which is found in tuna and industrial waste or elemental mercury which used to be found in old school thermometers (You may have even played with spheres of it as a kid if you’re an old fogey, like me). These are the types of mercury that we really worry about.  With methylmercury there are so many ways we are exposed and with elemental mercury we’re usually exposed to a lot when we’re exposed (like playing with broken thermometers).

Methylmercury is the one that makes us warn pregnant women about salmon intake.  Elemental mercury is the kind was used when making felt hats, giving the makers neurological damage centuries ago, i.e. The Mad Hatter. It takes about six weeks for the body to break this substance down to its ineffective state. In the meantime, the compound binds strongly to fat and neurological tissue; it finds its way to the brain, where it causes intellectual deficits.

This is why it’s important for people like De Niro to know the difference between mercury compounds, but he didn’t (or he doesn’t).

How did we get to this point? Why are parents distrusting of the scientists and physicians they chose, and continue to choose to listen to celebrities and snake oil salesmen?  Why are we still discussing something that’s not even in early childhood vaccines any more?  Why are we talking about “mercury” that was never even in the MMR vaccine to begin with?

I believe that three, nearly concurrent events happened almost twenty years ago that set this phenomenon in motion:

1) The FDA Modernization Act of 1997 required vaccine manufacturers to give detailed information to the government about all mercury-containing products. At the time, jabs for Hepatitis B, DTaP (diphtheria, tetanus and pertussis) and inactivated Polio had trace to small amounts of thimerosal (a mercury-based preservative) in their ingredients.

2) In 1998, Andrew Wakefield, a UK gastroenterologist published his infamous study in the Lancet that claimed a link between the MMR vaccine and autism (that’s since been retracted – more on that in a moment).

3) After vaccination rates declined because parents were so concerned about Wakefield’s study and lots of talk about thimerosal the CDC recommended the FDA order thimerosal removed from early childhood vaccines (except for the flu shot).  We’re still talking about this 15 years later, so pulling thimerosal from the vaccines didn’t work.

After the FDA Modernization Act, and widespread fears about autism following the paper published by Wakefield, there was quite a bit of public outcry for changes to be made in vaccines. In spite of good scientific evidence that there was no link between thimerosal and autism, government agencies and vaccine manufacturers decided to make all childhood vaccines thimerosal free. This decision placated some, but many pediatricians feel that it served as a capitulation to non-science. Thimerosal, at this point, only exists for children in certain flu vaccines. There is no thimerosal in the dose for children from 0 to 3 years-old.

In terms of Wakefield’s claim, his paper stating that a combined MMR vaccine was linked to autism was retracted in 2010 and his license to practice medicine was stripped in the same year. In the eyes of many health professionals, however, the damage had already been done. Vaccine rates dropped in several Western nations in the early 2000s, leading to multiple outbreaks of diseases that had been on a steady decline or even eradicated from some countries.

In spite of the overwhelming, worldwide, scientific evidence that vaccinations are safe and effective, claims of “toxins” and “poisonings” continue on the internet and at family gatherings. I won’t link to them here, but trust me. My job, as I see it, is to continue to fight the good fight against vaccine misinformation. The more people understand what we are giving their children, the more vaccine uptake and suffering prevented.

Yet we still have neighbors, family members, and very high-profile celebrities who are against or that “question” the safety of vaccinations. You know the ones: they show up on your Facebook timeline once a week with a story about “the medical industrial complex” or tell you that Big Pharma is out to make money by “making our kids zombies.” These folk often have a dubious story to share about a medical catastrophe or grand claims about medical marijuana curing cancer along the lines of “it also raised my cousin Scott from the dead.”

They seem to be proliferating and we’re seeing these diseases come back: an intentionally unvaccinated child recently died of diptheria in Spain, the first case seen there since the 1980s.  Then there was the measles outbreak that began in Disneyland last year, largely fueled by families that had refused to vaccinate their children.

While unrelated scientifically (do I need to repeat myself, MMR vaccines never had thimerosal as an ingredient), these three events became the bedrock of the modern anti-vaccination movement. The headlines falsely claiming that vaccines cause autism spread quickly throughout the Western world, and vaccine rates plummeted.  Once it’s out there you can’t get the genie back in the bottle.

The reality is that vaccine programs have been heralded as the greatest medical innovation of the last hundred years. We have drastically decreased deaths from vaccine preventable diseases. Even cervical cancer is getting its butt kicked. We need to keep it that way.

Editor’s Note 2.16.17 | This post was updated to better reflect the difference between the historic uses of elemental mercury.

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Categories: Disability + Disability Advocacy, Infectious Disease + Vaccines, Science 101 + Mythbusting

Vaccines Don’t Cause Autism, But That’s Not the Point

By March 7, 2016 26 Comments
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 When I was studying vaccine safety communication in grad school, I didn’t really think about autism as being a part of the conversation. That correlation had been disproved so thoroughly time and time again, I thought about autism only in a statistical sense. I thought of it in terms of t-tests and chi-squares.

Yes, I had loved ones that were on the autism spectrum or had children that were to varying degrees and I appreciated the challenges they faced, but vaccines were never part of our conversation, and why would they be?  Hundreds of studies with hundreds of thousands of data points both retrospective and prospective, and the correlation had been disproven.

At times when we’re faced with a parent or a friend that has a concern about something, we try to allay their concerns instead of addressing whether those concerns were valid to begin with.  In a clinical setting providers have a short period of time to address parents’ concerns and having a larger conversation about risk and what it means to have a child with autism really means just isn’t feasible.  The conversation gets shortened to simply “vaccines don’t cause autism.”  I cringe to admit it now, but I was once part of that problem.

As Julia and I say over and over again on this site, language matters, and I didn’t realize how much my comments could have hurt some people. But as Julia and I also say, it’s OK and important to change your mind with new information. This is the story of how I came to change how I think about vaccines and autism.

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Categories: Disability + Disability Advocacy, Infectious Disease + Vaccines

My Son Deserves to See His Fourth Birthday

By February 3, 2016 5 Comments
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A few days ago a plea I made on Facebook for my son’s life went viral. As of today it’s been shared over 6,000 times, but still I worry my plea has been unheard.

My son, my precious two year old Atticus, is fighting a form of childhood cancer called Acute Lymphoblastic Leukemia (ALL), right now. Except for the cancer and his treatment he’s like every other two-year-old. He loves dinosaurs, silly jokes, his dog, his five-year-old sister and did I mention dinosaurs? Atticus is a hefty, strong kid – I have never had to put a band-aid on him, he’d never had an ear infection, never had a fever, never threw up, he was literally never sick a day in his life until he got cancer.

His type of leukemia, ALL, is the most common, most researched childhood cancer, yet it cannot be predicted or prevented, only treated. Everyone who has ever met my AtticusterMan is always amazed at just how happy he is. His baseline for existing is just to see the world as all sunshine and rainbows, and I have done my best to keep that for him. He actually loves broccoli, but the chemo has killed off most of his taste buds, so right now, nothing except super strongly flavored food tastes like anything to him. So we do what we can to get him to eat.

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Categories: Ages + Stages, Chronic Illnesses + Conditions, Infectious Disease + Vaccines, Newborns + Infants, Toddlers + Preschoolers

Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick?

By January 10, 2016 14 Comments
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As a neonatal nurse specialist, mothers often ask me about the antibodies found in breast milk and how they can work to protect their babies. To explain it to them, and to you, I have to delve into immunology, and those conversations are usually too technical for most readers and mothers I meet in the NICU. Unfortunately, the information that is readily available to mothers that isn’t highly technical is a large body of conflicting information. So I’m here to talk more about this very important topic in a way that makes it straightforward! My goal is to answer very common reader questions like these:

“Why does my infant need any vaccines at all since she’s getting all the antibodies she needs from my breast milk?” and,

“Why does my seven-month old son need to get a flu shot if I received it during my pregnancy?”

Both, excellent questions! Parents, take note – there are 2 ways babies acquire immunity: through passive transfer, and active transfer (also known as acquired immunity).

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Categories: Ages + Stages, Food, Nutrition, + Infant Feeding, Infectious Disease + Vaccines, Newborns + Infants

Keep Your Sick Kid Home and Away From Mine!

By December 8, 2015 1 Comment
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We all know that dreaded feeling when you’re meeting with someone and their children, and you can immediately tell that they or their children are ill.

When that happens to me, I mentally start preparing myself for the impending sickness that is almost certain to be passed along to my family, and then I try to manage the disappointment and fleeting rage that momentarily crosses my mind. Sure enough, later that evening I’m usually woken up in the middle of the night by a crying child, and I can tell that something is amiss based on the pathetic-sounding cry and whine. I sleepily fumble my way into to their room only to find a shaky, feverish kiddo that’s miserable and immediately my mind flashes back when I had that sick visitor or play date.

Don’t get me wrong. I’m not a germaphobe, and some exposure to viruses is a good thing. Exposure to some germs is a necessary evil that helps beef up the body’s immunity, allowing our bodies to more effectively fight future illnesses.  One study showcased in Science Magazine has even shown that mice exposed to millions of bacteria and organisms fared better than those mice that essentially were raised in a sterile “bubble,” because their bodies were able to more efficiently fight against illness.

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Categories: Ages + Stages, Infectious Disease + Vaccines, Newborns + Infants, Policy, Politics, + Pop Health, School-Aged Children, Toddlers + Preschoolers, Tweens + Teens

How I Got H1N1 (the “Swine Flu”) and Changed My Mind About Vaccines  

By December 7, 2015 1 Comment
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About 10 years ago I thought vaccines caused autism. I didn’t believe this fallacy with any fervor or passion – in fact, I hadn’t researched it any sense of the word.  It was just something I’d picked up from what I call background noise, the kind of passive media consumption we all tend to do in this super-technical world we live in.

Then I was hospitalized with a vaccine preventable disease  – and I suddenly cared a lot about vaccines, autism and how one person’s decisions can impact a community.

I was in my mid-20s when it happened. I didn’t have any kids or plans for kids in my immediate future, so vaccines and autism were not things at the forefront of my mind. I’d had all my shots as a kid, I got an annual flu shot, but that was about as far as I went when it came to vaccinations.

It was during the height of the H1N1 media hysteria (or the “swine flu,” as it was dubbed, based on its common animal host) when my husband and I attended a party with some friends.  I was 27 and despite the excessive media coverage, catching that virus wasn’t something I was concerned about.  I was young and healthy with no major medical issues.  If I got it, I figured, it would just be a bad flu, and I’d survive. I was above the media hype.

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Categories: Faith + Beliefs, Infectious Disease + Vaccines, Science 101 + Mythbusting

Big-Ticket Political Debates Avoid Key Health Science Topics. Here’s Why.

By October 14, 2015 1 Comment
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CNN’s first Democratic Presidential Debate aired on Tuesday night, reminding us here at The Scientific Parent that scientific issues that affect our health aren’t a priority in big-ticket politics.

If you caught our coverage of CNN’s Republican Presidential Debate last month, you might have seen my *ahem* slightly irate post about how Donald Trump and Dr. Ben Carson sidestepped acknowledging that vaccines and autism are in fact, not connected. While it was disappointing, it wasn’t surprising.

Regardless of which side of the mythical party line you stand on, there’s one thing that’s pretty obvious…politics, particularly political campaigns, aren’t heavily driven by scientific or quantitative topics (as this science literacy drinking game reminds us). Driven by the behavioral science of voting and viewing patterns, yes. But political scientific topics like vaccines and vaccine legislation, a healthcare system that focuses on maintaining good health rather than our current system that focuses on care for chronic illness, or maternity leave legislation, to name a few?

Nope. 

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Categories: Policy, Politics, + Pop Health, Science 101 + Mythbusting