This one is a long one as this chapter is more intricate. The chapter aims to level criticisms at each individual vaccine. Here we talk about their distortions of virus/ bacteria derived immunity, versus their mistakes in the interpretation of community versus sterilizing immunity.

1. At the individual level immunity to disease may be acquired naturally or artificially (through vaccination)

At first this sentence seems innocuous, but this wording is very intentional to help them set up antivax tropes later in the chapter. If you think literally and carefully about what the word “artificial” means, you will be able to realize that it doesn’t actually apply to immunization. The immune system was still working to recognize the vaccine and develop immunity for the person receiving it. No robot, or Doordash, or cat on a Roomba was necessary to deliver the immunity. Something close to artificial immunity in the sense of the word that the authors are using is, delivering antibodies from a container to a person to give the person temporary immunity. Vaccines are not antibodies, they help produce antibodies.

2. For a vaccine to generate herd immunity, it must protect against infection with the disease pathogen so that the vaccinated cannot infect the unvaccinated. Correspondingly, a vaccine that does not protect against infection and transmission of a pathogen cannot confer herd immunity – and cannot eradicate the disease.

Here the authors attempted to pass off a statement as epidemiological fact by trying to use absolute statements. They’re wrong again, just like they have been wrong for the past 8 chapters. If you know what you are looking at, you can see the holes in the authors understandings of herd immunity. We need to take this definition by definition to pick the sentence apart. A bunch of poorly drawn pictures taped together passing as a cheetah portrait, is still a bunch of poorly drawn pictures.

Herd immunity is defined as the combined immunity from vaccination and infection, that allows for a population to receive indirect protection from contagious disease. Sterilizing immunity is the prevention of effective virus or bacterial infection of the host. As a consequence of achieving sterilizing immunity, forward transmission of a virus/ bacteria can be blocked (you can’t give it to another person if you don’t have it yourself). Depending on the actual virus/ bacteria/ fungus involved, sterilizing immunity is sometimes actually quite a high bar for a vaccine to achieve. One example of a vaccine that does achieve sterilizing immunity is the HPV vaccination, meaning that although there are several types of HPV virus, once vaccinated against the major strains that cause most cervical cancer in women, the recipients of the vaccination no longer have to worry about effective viral infection by those strains, and thus can no longer pass on the virus to other people. Another vaccine that achieved this high bar is the smallpox vaccination.

The other major logical hole in this line of thinking is that a disease does not have to be eradicated completely to make vaccination worthwhile (which applies to most vaccinations in the modern age and across political parties). Epidemiologically, economically, politically, and on an individual level, decreasing the morbidity of the disease pays dividends. For example, it is well known that rotavirus vaccination protects against mortality quite well, but because it does not induce sterilizing immunity, the vaccination still allows some mild disease to occur. However, the amount of babies saved from hospitalization and death from dehydration was well worth the effort to produce the rotavirus vaccine. It is not debatable that rotavirus still circulates around the world, but its associated morbidity has declined a lot, thanks to rotavirus immunization. Despite these known weaknesses of the rotavirus vaccination, this group used the meta-analysis technique to show evidence of herd immunity with receipt of rotavirus immunization. Take home point – it is not necessary for a vaccine to totally block infection transmission for a recipient population to receive its benefits (which is another common antivaxxer fallacy).

3. If the benefits of vaccines were limited to the vaccinated … each person (or legal guardian in the case of children) should have the right to decide for themselves whether to receive any or all recommended vaccines. But if vaccines provided protection to both the vaccinated and the unvaccinated, then mandating them in the name of the public good would not be that farfetched, despite the restriction of individuals’ freedom.

Recipients of vaccines benefit the most from receiving them, and the unvaccinated community benefit as well when community immunity is reached. To the extreme, there are people whose immune systems genuinely cannot tolerate a disease or its vaccine (MMR), and whose lives depend on community immunity to not catch the corresponding disease. Such people are also not rare – ask if you know anyone in your community ever had to deal with cancer.

The epidemiological data are clear that people who remain unvaccinated do gain protection from those people who received immunization. To what degree? Lets look at the actual research. People who have certain types of immunocompromise have a genuine medical contraindication to measles vaccination, because these are attenuated viruses that can actually set up a real measles infection in certain types of immunocompromise. This population has the highest benefit from getting population immunity as high as possible from measles immunization. This is not only case study level evidence – this particular contraindication is established for every country that carries the MMR vaccination. For most everyday scenarios, we’ll want to know if the general unvaccinated patient benefits from living in a community with strong herd/ community immunity.

The largest modern day experiment addressing this problem is the COVID pandemic – and we have multiple data from multiple points in time affirming the hypothesis that people unvaccinated against COVID were more likely to die/ get hospitalized than those who received vaccination. People who remain unvaccinated, do indeed benefit from living within a community that is highly vaccinated for COVID (although the power of the effect is milder than that of other viral diseases). The profound difficulty in achieving classical herd immunity with COVID is recognized; this is likely a function of how fast the infection occurs and how fast the virus mutates.

How about another disease – a special subtype of meningitis reveals one of several lines of evidence that people benefit from being vaccinated against meningitis, but also benefit from herd immunity even when unvaccinated. This study shows that such unvaccinated populations have less asymptomatic carriage of the meningitis bacteria and less severe disease (but they do recognize the need to do something like a cluster RCT and observational trial to measure the effect in the most robust manner). As is the case in meningitis, a public health agency does not need to wait for every possible study to be done from every possible perspective before acting against an infectious disease and recommending vaccination. The outcomes of severe meningitis are so horrible that the population deserves protection. While it is certainly correct that every new disease requires new vaccine research and new research into a herd immunity threshold, we have plenty of historical evidence at this point to encourage us to try, every single time.

4. To substantiate the claim that vaccines are both personally and societally beneficial, their disease-reduction capabilities need to be weighed against their side effects… Only such a comprehensive and detailed analysis can provide a solid evidentiary basis for the claim that the individual and societal benefits of vaccines outweigh their harms.

This sentence is simultaneously a gish gallop, a goalpost shift, and a future goalpost shift. One only has to read through the posts of Children’s Health Defense (and Science Based Medicine) to see that once antivaxxers have one of their demands met, they come up with another demand. This is because they have no interest in having a genuine scientific debate, they have an interest in stoking up fear about vaccines. Lets address each of their claims right now.

Reductions in infectious disease – In the early variants of COVID it was clear that the amount of infectious disease was reduced with vaccination. Hepatitis A prevalence has been significantly decreased thanks to vaccination. Strep pneumoniae, Hemophilus influenzae, and meningitis have all decreased in prevalence thanks to vaccination.

Reductions in disease related hospitalization – the modern situation with COVID variants has resulted in vaccines that do not prevent infection quite as well anymore, but the benefit in reducing hospitalization with severe COVID disease remains very, very clear, even in 2024.

In previously preterm infants, the receipt of pertussis vaccination was associated with a lower risk of needing hospitalization for the disease. Smallpox was eradicated with vaccination – so the amount of hospitalization still occuring is effectively zero.

The following study is a mathematical modelling study for hepatitis A, but the vaccine has been shown to reduce hospitalization with hepatitis A disease.

The CDC Pink Book can be reviewed for readers who want to verify that each of the vaccinations did indeed reduce hospitalization after receipt of vaccination (for each of the other vaccine preventable diseases). There are also multiple different types of analyses of the cost benefit ratio for specific vaccines in special populations such as those who are immunocompromised with HIV.

Reduction in need for medications/ lost workdays – most kids don’t have workdays, but the evidence in reducing hospitalization from the above links is quite clear. When less hospitalization is needed, less medication is needed, and there are less long term adverse health outcomes and loss of productivity in school.

Price of vaccines – the comparison of the individual cost to the patient for a hospitalization for a vaccine preventable disease in the United States versus the cost of the corresponding vaccination is very, very clear. Vaccines cost in the tens to hundreds of dollars, and hospitalizations cost at least tens of thousands of dollars in the US. What might the cost be in the most extreme scenarios? Up to a million dollars at time in the United States.

Costs of distribution – the cost of assembling a vaccine, packaging a vaccine, putting a vaccine in a truck and sending it to the end user are factored into the final vaccine price. However, there may be costs associated with giving out the vaccines (meaning the costs of paying the healthcare employee to give out the vaccine to the end user). Such costs would be typically billed to insurance as a visit fee, but again, these costs pale in comparison to the cost associated with a hospitalization for a vaccine preventable disease in the United States. In countries with socialized medicine, the cost of both to the consumer is minimal to free, but a hospitalization with a vaccine preventable disease is still substantial in terms of lost productivity, adverse healthcare outcomes, and sometimes mortality (in every country, socialized medicine or not). By the way, while certain insurance companies may incentivize vaccination some of the time, this is definitely not generally applicable. Most pediatricians actually break even or lose money on vaccines.

Comparison of side effects versus benefits – every new vaccine gets at least one, at times, several ACIP/FDA sessions (American College of Immunization Practices and US Food and Drug Administration) comparing side effects versus benefits. This doesn’t count all the secondary research done outside the FDA that their staff consider. To claim this analysis doesn’t occur is a failure of very simple fact checking.

Indirect costs (medical treatment for side effects, loss of parental workdays, loss of future earnings) – an economic analysis has been performed for the COVID19 vaccines in NYC and it demonstrated a net economic benefit. The overall economic cost-benefit analysis of the entire childhood vaccine schedule also has been analyzed, in time for the publication in this book, by the way, and the lack of a thoughtful discussion on this suggests it was intentionally de-emphasized. There were multiple levels of benefit including cost savings in prevention of hospitalization, prevention of cases of vaccine preventable disease, and savings in total societal costs. Perhaps the authors didn’t want to get into the article due to the first author being a CDC employee at the time of the publication of the article. Here’s another article that speaks to the overall positive return on investment in vaccinating against childhood vaccine preventable diseases. Perhaps the authors don’t want to discuss that article because Merck was partially involved in the funding. Here’s yet another paper that speaks to the economic benefit of India’s Universal Vaccination Programme. Perhaps this paper wasn’t discussed because it was funded in part by the Bill and Melinda Gates foundation. However, the authors specifically mention that the funders had no role in the design/ data analysis of the project. Such projects cost money just like any other research projects, and the world would be interested in seeing what ideas Mary Holland of Childrens Health Defense may have in getting alternative funding sources if the ones I indicated are not satisfactory. If one looks at this via a purely insurance company/ economic perspective – a health insurance company/ national health insurance payor would much rather pay for a preventative visit than a hospitalization for the corresponding vaccine preventable disease, every single time. In light of the economic benefits, we can rationally discuss the current shortcomings of compensation for genuine vaccination associated adverse events, through the work of professors with actual experience in the field such as Dorit Reiss. There’s enough vaccine side effect research out there that the authors should not feel the need to lie about said research. Even provax physicians have empathy for people who have genuinely experienced a side effect (and could get behind better compensation). In summary, the authors can only claim there were no economic cost-benefit analyses if they intentionally didn’t look.

5. The trial demonstrated that the vaccine was effective in preventing invasive pneumococcal disease: Among the 19,000 infants who were vaccinated with Prevnar, there were 18 fewer cases than expected. But in the same trial, … the trial results raise the serious possibility that the vaccine’s side effects far outweigh its benefits.

First off, if you only read one study, you can get the false assumption that Prevnar doesn’t do that much to prevent invasive pneumococcal disease. One can also put on blinders to the fact that infectious disease physicians were well aware of the issues with PCV13 not covering enough pneumococcal strains, which directly motivated the subsequent invention of the more modern iterations of the vaccination, Prevnar 20, and PPSV23.

In this part of the chapter they also complain about saline placebos. This is code for an old antivax fallacy of how “there were no saline placebos used”; in fact a large number of vaccine trials used saline placebos. As usual, antivaxxers can’t read or don’t want to. This line of thinking ignores research that even plain saline placebos create side effects (despite the fact they are water and salt). This line of thinking most importantly ignores the now extensive body of research into Prevnar 13’s side effects, as listed via its own vaccine package insert. People who write books like Turtles all the way Down strongly advocate for reading vaccine inserts by the way, which they appear to not have done here. The research they claim was not done, is literally on the package inserts. What happened to following their own advice?

6. As we’ve seen, the true rates of common short-term vaccine side effects are unknown …[and] chronic morbidity in children has been rising steadily since the middle of the 20th century in step with the increase in vaccine use.

When I need to learn about public health, I prefer to reach for people actually trained in the subject, because they have acquired the logical thinking necessary to holistically assess the specific scientific subspecialty. An introduction to the rates of common short term side effects is listed on each major vaccine insert. The causes of the rise in American obesity are multifactorial. The research into this topic has gone on since at least 2009 and earlier. The causes of the rise in asthma are multifactorial. The causes of the apparent worsening in seasonal allergies, as discussed by an actual school of medicine, are introduced here. Finally, multiple hospitals have looked into the relationship between vaccines and chronic allergy, and no, there is no relationship. Just because the age of Miss America contestants across the years is correlated with the rates of murder by hot objects, doesn’t mean the two items are correlated. Vaccines do not cause obesity, asthma, or diabetes, based upon the previously cited very extensive body of evidence.

7. Universally imposing a medical intervention that carries serious risks should be inconceivable without first providing conclusive proof of its net benefit to both the individual and the society.

As an adult, choosing not to read the proof is a conscious choice on the part of the authors (as is goalpost shifting). The above few points should make it clear that plenty of proof is available to the reader. What is the biggest reason everyone is offered routine childhood vaccination – everyone is a potential candidate to get infected with a vaccine preventable disease before they are vaccinated. There is plenty of vaccine side effect research available to the reader; a fine starting point is the vaccine inserts (which are available for free download off the US FDA website). It is an unresaonable expectation to want a physician to go over it all in the span of one office visit – but pediatricians as a whole welcome sincere questions over the span of several visits if needed (or via electronic messaging). Www.vaccinetalk.org is a well moderated forum (on Facebook) staffed by mainstream physicians and volunteers where additional questions can be asked if needed.

8. Despite their importance to vaccine policy, herd-immunity-threshold computations are based on a rather sketchy theoretical scientific foundation.

As usual if the authors choose not to read the articles that go against their previously established beliefs, they can think scientific foundations are as sketchy as they want them to be. Herd immunity has slightly different descriptions depending on the book the reader consults, but it is generally some variation on the amount of immunity in a population required to tip the amount of disease present into decline. Interested readers who wish to pursue the topic in great detail can reference this article. Mathematically, the calculation in its simplest form is 1 – 1/R0, where R0 is the average number of people infected by an infected person. This calculation is just an estimation, and the reason there is debate over what the herd immunity threshold is, is because the other contributing variables that go into the calculation sometimes change over time. Two of those variables are the degree of population mixing and the speed of spread of a virus in different communities – which both may be moving targets. Public health professionals are well aware of the limitations of the herd immunity calculation as discussed in the book and, lots of work/ debate went into calculating well established herd immunity thresholds like that of measles. Here, the authors chose to ignore the science and insult it, rather than realizing that herd immunity threshold computations are a routine part of public health training programs (when those degree programs specialize in a field related to vaccines).

9. In the US in 1947, a year before the tetanus vaccine came into wide use, morbidity was already quite low at 0.39 cases per 100,000. This rate continued to decline gradually after the vaccine was introduced.

This statement completely ignores the degree of morbidity and mortality that occurs with tetanus in patients who do genuinely require hospitalization. When the morbidity is small, this by itself does not mean that further reductions in morbidity are meaningless especially when the severity of tetanus disease is well known. The description of herd immunity as it relates to tetanus vaccination is generally correct in that it is very hard to generate herd immunity when the primary mode of transmission is through contact with broken skin/ cuts with dirty metal. However, it is still very important to protect against real tetanus infection.

10. Debate on whether polio vaccines confer herd immunity is largely based on conjecture intended to bridge the gap between theory and reality. For example, researchers are incapable of providing an evidence-based explanation for the disappearance of poliovirus from the US as early as 1970, even though the OPV vaccination rate was only at around 65 percent in children, and much lower in adults. Did the poliovirus actually disappear from the United States? And if so, did it disappear because Sabin’s vaccine generated herd immunity? Did the vaccine’s attenuated poliovirus, excreted in the stools of the vaccinated, seize the ecological niche that was formerly inhabited by the wild poliovirus and thus push it out of the country?

They have again used the gish gallop technique to appear impressive but let’s take a moment to look at what their allegations actually are.
– They don’t think polio researchers have a convincing explanation as to why polio started declining before the vaccines rolled out (they think polio decreased substantially around 1970)
– They don’t think IPV (inactivated polio vaccine) is good enough to generate herd immunity
– they do not believe the IPV vaccine was responsible for the disappearance of polio (and cannot be used for the eventual goal of eradicating polio)

The overall logical hole used here is complaining that a specific tool does not do a job it is not designed for, while ignoring that polio researchers are quite aware of the benefits, risks, and tradeoffs in countries using IPV versus OPV.

Ultimately we can all get behind being against the most nasty outcome of the OPV (oral polio) vaccine – which is despite its attenuation, sometimes the virus mutates in the wild, and if it finds its way back into a human, it can cause vaccine derived paralytic polio. Infectious disease researchers all around agree this is a horrible outcome. However, to address all the rest of the authors claims, requires some background in understanding the polio vaccines three major subtypes.

The disease, named polio, is caused by 3 major subtypes of poliovirus, which are creatively named 1, 2, and 3. IPV is a poliovirus vaccine that is chemically inactivated meaning, the whole virus is there, but it is impossible for it to cause disease. The main benefit of this vaccine is that it allows antibodies to help form immunity against the virus. The main tradeoff, like the authors said, is that it is not as great (but not useless) at inducing immunity in the intestines, which are one of the main portals of entry of the virus in humans. This is where the OPV comes in, which in its original form, carries all three viruses but in their attenuated forms.

This means OPV vaccines are created by copying them in cell cultures, but copied enough times so that their viral genome comes with mistakes, so that they have less of a risk of causing disease. Two of the major advantages of this vaccine are substantially lower cost of production, and the ability to store this oral vaccine (it’s given on a sugar cube) in a typical fridge, which is great for lower income nations. The second type of poliovirus has been eradicated in the wild in 1999, so the original oral vaccine (not the one available in America which is IPV) which still carries type 2, now carries a higher risk than benefit, so it is in the process of being phased out.

Countries that currently use OPV cannot just immediately switch to all IPV due to financial and logistical reasons. One of the biggest reasons – retiring OPV still means that countries have to work on distributing the newer IPV, which could set up several holes in herd immunity resulting in paralytic polio outbreaks. There’s a World Health Organization plan spelled out line by line, with the criteria that must be met for transition to the Inactivated Polio Vaccine.

The incidence of symptomatic polio is well known in CDC charts (Centers for Disease Control and Prevention (CDC). Immunization Against Disease–1972) – the incidence of polio started declining in 1952. The inactivated polio vaccine was first released to the American public in 1955. The oral polio vaccine was introduced in 1962, and both of them together helped precipitiously decrease the incidence of symptomatic and paralytic polio in the United States. So, the first claim can be dismissed as failure to read the actual epidemiology (the incidence of polio in 1970 was much smaller than in 1950 in the US, thanks to vaccines).

The third claim is partially true in that it accounts for the possibility of vaccine associated paralytic poliomyelitis, but this was one of the big reasons the US switched to IPV when it did (and not to mention ignorant of all the work the WHO is doing to try and change vaccine regimens to fix this exact problem of vaccine derived paralytic polio). Their last claim, on doubt of herd immunity – is again a reflection of their omission of information in the Vaccines book by Professor Plotkin. While it is accurate that IPV and OPV have their drawbacks, a comparison of the observed incidence of US polio cases, the expected incidence in the complete absence of vaccine use, and the expected effect if vaccine benefit was only endowed upon the vaccine recipients, was performed. The amount of cases went down more sharply than what would be expected if vaccine benefit was only seen in the vaccine recipients. In short – both vaccinated and unvaccinated benefited from the distribution of polio vaccination.

11. Although the [pertussis] vaccine has been in general use for the past seventy years, the way in which it curbs the spread of the pertussis bacterium( Bordetella pertussis ) has almost never been studied, and experiments testing its ability to prevent human infection and person-to-person transmission have never been performed.

If the authors fail to read the literature they don’t like to hear, they will be able to come up with any conclusion they like. First, pertussis is a bacteria that has the potential to develop into a pneumonia, and it is most harmful to our youngest patients where it can land them in the hospital or cause them to die of the pneumonia. This is why this age group needs the vaccine the most and one of the biggest reasons the vaccine is started in this age group (as DTaP). Both the bacteria and the toxin it creates participate in the disease called pertussis.

Whooping cough is highly contagious, and people are most infectious during the initial stage of symptoms. The bacteria itself are spread along large respiratory droplets. Symptom free spread is a thing (asymptomatic spread), and humans are the only known natural reservoir. A hole in the vaccine’s ability to protect against asymptomatic infection (and thus create carriers) is acknowledged, however the protection against severe disease in those who are vaccinated still remains strong. This does not by itself mean the vaccine is not helpful, contrary to the claims in the chapter (many vaccines are not capable of perfect or near perfect sterilizing immunity).

The study I just cited also makes the second part of the author’s sentence objectively false, as do several other studies looking at pertussis and human to human transmission.

Next, contrary to their beliefs that the ability to stop infection has not been tested, it actually has been tested. The full answer requires several steps – first we need to demonstrate that good antibodies can be elicited, and the MAPT trial accomplished this (via comparison of 13 acellular pertussis vaccines with the old whole cell pertussis vaccine). There actually were complexities in the initial attempts to demonstrate a clinical correlate of protection – that is, a blood test that can reliably tell a doctor how well a patient is protected. It is possible that the overarching misconception in this chapter started there.

Next, studies trying to establish correlates of protection and how well pertussis vaccine prevents pertussis disease, have been going on since at least 1992. Like described in the chapter, antibodies do wane faster than the ability of the vaccine to protect against pertussis disease, but that ability to protect against severe disease is still worthwhile – in fact cell mediated responses play a role in providing the recipient ongoing protection.

12. Despite the fact that Warfel 2014’s findings nullified some recommendations pertaining to pertussis vaccination from health authorities around the world by highlighting the shortcomings of the pertussis vaccine and its role in the recent surge in pertussis morbidity… natural disease conferred individual immunity superior to that of the vaccine.

The shortcomings of the vaccine are some knowledge gaps in how the full picture of immunity is achieved… but as described above this statement alone does not make the immunization useless. The statement above also illustrates an absence of awareness of the cost of making infants gamble with severe pertussis disease (before they can have a fighting chance at immunity acquired by the actual disease). This is akin to saying one must get toughened up against car crashes by getting into lots of car crashes.

Citing only Warfel’s findings ignores the findings in the previous point, that protection against severe pertussis disease is worth having. Furthermore, the allegation that pertussis transmission has not been tested is objectively false. The whole cell pertussis vaccine (retired in the United States in large part due to side effects) does give the recipient some herd immunity and protection from transmission.

Immunity acquired with infection requires that one potentially deal with all the medical consequences of infection, before the benefits can be reaped. The hole in the ability of pertussis vaccination to generate long lasting herd immunity is recognized, especially by infectious disease physicians, but this statement alone does not negate the benefits of giving vaccine derived immunity to those citizens who are the most vulnerable (our infants).

Even in the modern age, there is discussion on whether or not to make a better whole cell pertussis vaccine (and other types) for this exact reason. It is a significant logical error to simply assume that infants are not worth protecting (which is what happens when the authors state that “natural immunity is better”). Despite the author’s complaints that this information is being “withheld”, this information is readily available from pediatricians everywhere. If the information were really being withheld CIA style, nobody would know it.

13. “Cocooning” requires that members of an infant’s immediate family (including parents, grandparents, and siblings) be vaccinated shortly before the infant’s birth, assuming they will then serve as a protective shield against infection with the pertussis bacterium. This guideline, which is currently practiced in many industrialized countries, was established despite the absence of solid evidence that the vaccine provided such protection.

First, newborn infants cannot get a pertussis vaccine right at birth because their immune systems are not mature enough to process the DTaP vaccine effectively. The recommendation to vaccinate mums and immediate contacts arises from the need to protect these infants before their first vaccination.

Next, vaccination of the mother does efficiently transfer protective antibodies to the infant.

Next, infants do receive worthwhile protection from symptomatic pertussis disease if their mothers are vaccinated. Before it was known that maternal Tdap vaccination (adult version of DTaP) is safe in pregnancy, there was actually a period where the recommendation to vaccinate all mums was not made (despite there being infants getting hospitalized with pertussis). Now, the official recommendation is to proceed with maternal vaccination and time it in such a way that maximum immunity for the infant coincides with birth. The limitations of the cocooning approach are well known, and this is why national health agencies are not exactly knocking on the doors of county health departments to convince everyone to cocoon. The CDC itself explicitly describes the major limitations of pertussis cocooning. However, it is still worthwhile for an infant to receive as much protection as they can get. In other words, just because cocooning has its limitations, does not then mean we let all the infants get as much pertussis as possible.

14. Only the toxin-secreting strains [of diphtheria] cause the classic symptom of the growth of a thick membrane over the patient’s throat, a dangerous condition that can lead to death. Furthermore, even these strains cannot secrete the toxin if patients are not deficient in iron.

We start off this part of the chapter with multiple mistakes. First, the authors do not realize that sometimes words in scientific English mean different things than in conversational English. The expression “Patients are not deficient in iron” is very very different, biochemically speaking, from low iron levels. The strategy used here is to try and cherry pick bits and pieces of physiology, take them out of context, and create the impression the authors discovered something new.

What actually happened is they failed to holistically understand the article they cited (and even failed to read the actual summary of the article). Like the article stated, iron is a scarce resource and quite useful for a variety of chemical reactions in the body. The human body also follows this rule – the amount of free iron actually floating around in the body is quite small because the body is aware, that bacteria can use it for their purposes. In addition, iron atoms running free in the bloodstream actually cause harmful chemical reactions.

The vast majority of the iron stores live in the bone, blood cells, and serum ferritin (a box like protein that stores iron atoms on the interior). The amount of free iron sitting in the blood freely floating around has absolutely no correlation with the amount of total iron stores, even when a person has symptomatic iron deficiency anemia (the disease). All this information, put together, actually means that a prospective corynebacterium diphtheria bacteria is by default going to encounter low iron in its environment and produce the toxin (which means its going to cause symptomatic disease). The degree of iron deficiency of the person getting the infection doesn’t matter (although iron deficiency should be treated separately). The authors hoped the reader didn’t understand all this biology and could engage in more deception. I know what I’m looking at so I aim to help the reader decipher these issues.

15. The rate of severe morbidity and complications varies from outbreak to outbreak – the reason for this variance is unknown. The exact mode of transmission of the bacterium (diphtheria) is also unknown.

The author’s confusion about the primary mode of transmission would be resolved if they bothered to quote the part of Plotkin’s vaccines that doesn’t fit their narrative – diphtheria transmission is by large respiratory droplets. This text was in the same chapter but there is no evidence they read it (or perhaps did not review the newer edition).

The rate of severe morbidity and complications depends on the degree of vaccination of the community and access to care. The allegations that diphtheria vaccination do not produce herd immunity should be corrected – in that the more correct statement is that vaccination is not able to prevent asymptomatic carriage as well as severe disease, but this has the same logical hole as their allegations about pertussis.

Just because asymptomatic carriage is not completely blocked does not mean the protection against severe disease is not worthwhile. As usual, complete medical care, sometimes involving antibiotics, is optimal for prevention of morbidity and mortality from diphtheria.

16. Neither the efficacy nor the safety of the vaccine (DTaP) has ever been tested in a clinical trial.

No, a simple Google search will reveal quite a few studies done on the safety and efficacy of DTaP and Tdap.

17. In conclusion, the influenza vaccine does not confer significant herd protection due to frequent and impossible-to-predict changes in circulating strains, which entails annual re-formulation of the vaccine in anticipation of next season’s dominant strains. This results in a vaccine that is partially effective, at best, and occasionally utterly ineffective.

That the influenza vaccine has this problem is well known, which is why certain groups are attempting to work on a universal influenza vaccine that circumvents the problems that the virus gives us with shuffling its genome. The same erroneous logic is used here – lack of perfect herd immunity is not a sufficient argument on its own to say a vaccine is entirely useless.

18. Hepatitis A has no specific treatment, and patients receive only supportive care. Complications are rare, and so is mortality. But recovery time in adults can be relatively long – up to several months. Unlike hepatitis B, there is no chronic carriage of the virus. Infection grants immunity for life.

According to modern medical ethics a consenting adult can technically sign up to damage their health as much as they want, and a physician legally cannot stop him or her. However, the list of possible complications is very long, and includes liver failure, pancreatitis, cholestasis, kidney failure, autoimmune disease, and quite a few more (Plotkin’s vaccines). Most people would generally choose to avoid these if possible.

As is frequently the case, kids get less serious complications than adults who contract the equivalent disease, but this argument is frequently made to minimize pediatric disease (and thus argue against pediatric vaccination). That children get symptoms from hepatitis A in smaller proportions than adults is not a valid argument on its own to avoid creating a vaccine for that disease. Given that acute liver failure is a small but real risk to children, which may result in their needing a transplant – hepatitis A is worth protecting against. To get the protective antibodies while being unvaccinated, requires the person to gamble with getting the disease first.

19. The vast majority of [hepatitis B] infections occur through sexual contact, the use of dirty hypodermic needles (in medical procedures or narcotic drug injections), a carrier mother giving birth, or exposure to others’ bodily fluids through non-sexual contact.

This statement about hepatitis B makes multiple mistakes that attempt to hide behind a distorted emotional hook. I’ve heard enough professors of infectious disease teach, to know that actual experts in hepatitis B don’t use this as a common teaching tool. Yes, it is true that a big slice of infections from hepatitis B occur from IV drug use and unprotected sex. However, this ignores the fact that the younger the person at the time of infection, the more likely they are to get a chronic infection.

This ignores the multiple complications that hepatitis B can cause, including liver cancer. This ignores the fact that this disease does not have an effective cure at the current time (hepatitis C does have a cure but no FDA authorized vaccine at the moment).

This distorts the fact that hepatitis B might have a small absolute number of children getting infected each year as compared to more well known infectious disease like RSV and influenza, but that their morbidity is still important (a common theme throughout the whole book).

This ignores the fact that 10-25% of patients with chronic hepatitis B infection go on to get liver cancer, with a long latent period (meaning many decades may pass before they know they have cancer).

This ignores that the current low (but not zero) prevalence of hepatitis B infection in children is sustained, in large part, due to vaccines.

This ignores that vaccination is much more cost effective than the current lifetime of medicines that a patient with chronic infection will likely have to take (a cure may come but it is sure to be expensive initially).

This ignores that there are three modes of transmission – exposure through broken skin, exposure to open mucosal membranes, and transmission via inanimate objects.

While kids can certainly benefit from a family who is verified to not have hepatitis B, a child cannot be shielded from every possible inanimate object in the world that might have hepatitis viruses on it (those viruses are pretty hardy in the environment).

This thinking ignores that fact that mums can catch hepatitis B (doesn’t have to be through IV drug use) even after being tested as negative earlier in pregnancy. This ignores the fact that most people who are infected with hepatitis B don’t know they are infected, so cannot necessarily seek medical help.

This ignores that while it is great that hepatitis B cases in children have declined steeply since 1991, even in 2020, new acute and chronic cases are still being identified. The number of those cases pertinent to children is acknowledged as being a small number, but this fact alone is not adequate to argue against protecting kids from hepatitis B. “The risk of contracting the virus/bacteria is essentially zero anyway” is a theme used throughout the book to minimize many pediatric diseases, in an absence of awareness as to whether or not it is based in reality.

20. Rotavirus: the evidence accumulated thus far is not clear or consistent enough to provide unequivocal proof of a herd protection effect for the vaccine. Another limitation is that there are no biological studies confirming the existence of a vaccine induced herd protection.

At this point I hope the tactics used by the authors in this chapter are clear – the lack of perfect herd immunity is not a sufficient argument in itself to argue against producing a vaccination. The reasons for the holes in herd immunity can be varied and complicated. The bottom line for the potential recipient infant those, is a big reduction in risk of hospitalization for rotavirus gastroenteritis (vomiting, diarrhea, and dehydration).

21. Pneumococcal vaccine:there are primarily two allegations here – the vaccines do not cover all the strains of invasive pneumococcus and the protection wanes over time. Therefore, the author alleges this vaccination is not helpful.

The authors make the same logical mistake as in some of the previous paragraphs, so here so I will be brief and to the point – just because there are multiple subtypes of bacteria doesn’t mean the vaccine can’t be made against the most common subtypes, and be updated (we have a 23-valent vaccine now) when it is clear the previous subtypes were not being adequately covered. There is also evidence for cross reactivity, so the most commonly used PCV vaccine is not entirely unhelpful (protection against old variants protects against newer variants to some degree). Again, just because a vaccine does not generate perfect herd immunity does not mean, on its own, that it is useless.

22. Although solid evidence is lacking, [Hib] is assumed to be transmitted through droplets of fluid from the nose and throat, presumably following close and continuous contact.

No, the evidence is quite clear, the authors just declined to read it. The transmission is via respiratory droplets or via contact with infected secretions.

23. Varicella: Despite this, many countries have chosen not to include it in their vaccine programs, which implies that these countries do not regard the disease as a significant burden on public health.

This is an area of active debate however this does not mean what the authors say – public health agencies outside the US routinely make slightly different calls on what will be included in their national vaccine schedule. The classic example for varicella, is the difference between the British and US interpretation of the necessity of including it in the vaccine schedule (and as of 2024 this is looking like it will in fact be included in the British schedule). There is an economic argument, meaning that the British version of the American College of Immunization Practices did not initially believe the savings in chickenpox cases are not worth the price paid (remember the British NHS has to pay for all these vaccines, whereas in the US it is generally insurance companies). The medical argument presented in the chapter ignores that more recent studies have realized a younger age group that would be affected by the choice of removing childhood vaccination – so the older adults do not need to worry as much about getting zoster if the kids are getting vaccinated. Now, Britons can receive the chickenpox vaccine after consideration of all available data.

24. Rubella – the allegation here is that not enough outbreaks have occurred recently, and that it does not constitute a serious enough threat to the population to be taken seriously.

The authors again seem to have read just the parts of the Plotkin’s vaccine textbook that fit their narrative, and discarded important points that don’t fit their narrative. It is technically true that the viral infection doesn’t cause severe disease in most adults and children. However, it ignores the fact that there are still outbreaks with pregnant mums who didn’t know they were non-immune, and significant permanent birth defects occurred.

25. Issues with the summary paragraphs –

The train of logic in the summary paragraphs again forgets that infection derived immunity requires the patient live with the possible costs and risks of infection, in order to gain that immunity (and in the case of measles, wipe out all their prior immunity by killing the cells responsible for storing that information). In the modern age, there are routinely outbreaks of vaccine preventable disease in communities with low or waning immunity. Vaccines do not have to produce perfect herd immunity to be useful to the recipient. Finally, even by their own analysis, in the same chapter, they should understand that an unvaccinated and nonimmune person is protected by the collective immunity of their community (look at them not even being consistent with their own lines of thinking). By their citations they theoretically studied the vaccine textbook by Plotkin – but by their extensive mistakes, they clearly didn’t understand what they were reading (or chose not to).