How to Talk About The Bonus Value of Vaccinations

You’ve probably been seeing reports that vaccinations do more than just prevent the disease they were designed to counter: flu, RSV, shingles, Covid, and other vaccines are being shown to have important extra protective benefits. So, how is the medical community doing in passing along the good news? Well…sigh.

Here’s how a New York Times article introduced the topic:

“But other reasons for older people to be vaccinated are also emerging. They are known, in doctor-speak, as off-target benefits, meaning that the shots do good things beyond preventing the diseases they were designed to avert.”

“Off-target” benefits? Who lines up to get “off-target” anything? Clearly, we can improve on that language. Let’s start by recalling the “wisdom” of the infomercial. Say what you might about those ads, but they evolved by getting immediate feedback on what communication works and what doesn’t. And what they learned back in the 1970’s is that people respond to what came to be known as “value stacking.” This is where you promote the main item, then keep adding products/benefits, adding what’s known as “the sweeteners.” Thus, the classic line, “But wait, there’s more…”

(The first use of that line is thought to be in an infomercial for Ginsu knives, the work of marketing legend Ed Valenti.

The ad sold you on the knife itself, then kept adding more pieces to the package.)

The “but wait” line was planned to land near your decision point, to prevent drop-off and to make the offer increasingly generous until it feels like you’re losing out should you decide to not join in.

Sadly, we haven’t heard of anyone working on infomercials on vaccinations. So we turned to a man known for his ability to make medical issues clear and convincing — entertaining, even — Dr. Scott Hamstra, and asked for his help in preparing us all to talk more persuasively about vaccinations.

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Dr. Scott Hamstra, Captain (retired), pediatrician, served Arizona Native American communities as a US Public Health Service Officer for 24 years before retiring from Active Duty in 2014. Since then, as Medical Advisor to the STChealth, he shifted focus to expanding the impact of vaccination to the USA and the world. Living in Tucson, he continues to offer medical expertise to Native Americans.

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When we brought up the subject of being more persuasive about immunizations, Dr. Hamstra’s first thought was this:

I’ve long used the metaphor that vaccines are like seatbelts—they don’t prevent the car crash; they prevent you from being hurt during the car crash. I have found this helps many people understand vaccines. In hindsight, we may have been wise to promote this metaphor during COVID.  People were very upset when they got infected by COVID after getting the COVID vaccine, discounting how it helped them stay out of the hospital or the graveyard.

Over time, I have found that vaccines might offer more than simple seatbelt protection. Perhaps akin to new car technology that helps us avoid crashes (automatic braking, airbags, adaptive cruise control, blind spot detection), vaccines might keep us from damaging other internal structures by avoiding hitting the windshield or steering wheel.

Let’s start with measles. In preparing to talk with you, I read an article in Nature where they argued that having measles casts a “shadow” for years.  By “shadow,” they meant that it sufficiently damaged the immune system that it took years to recover.

Measles could be compared to the California fires – as it burns, it wipes out a lot of your natural biology. Then when the rains follow … oops… you don’t have your normal vegetation, and you suffer from flooding and mudslides.

Measles has long known to put us at risk for other infections. Measles “amnesia” describes how battling the virus erases the immune system’s memory, leaving the body vulnerable to other diseases for years afterward. Let’s use a war analogy. During the winning fight against measles, we used up lots of our defense resources, losing a lot of trained Army, Navy, Air Force, and Marine troops, equipment, and supplies.  

I love that analogy, and it’s important because there are plenty of Americans who recall having the measles and, looking back, take measles lightly. For instance, a New Yorker article wrote that RFK Jr. recalled it going through his large family and joking that it was a “great week” of watching ‘Sea Hunt’ on television while treating the flu with chicken soup and Vitamin A. 

Measles could be compared to fighting World War II; during the battles, there’s a lot of damage that takes time and effort to rebuild. For a while, two-to-three years post-measles, you’re susceptible to another invasion or another attack. More bad news, even after the war ends, sometimes there’s some ongoing battles in remote areas that seem unaware of the ceasefire or surrender. While most kids who make it through the acute measles fight seem ok, a few will go on to suffer progressive brain dysfunction, sclerosing panencephalitis. These kids die five or ten years later from this progressive brain disease, that starts as behavior change or intellectual problems, before seizures, blindness, and eventual death. For these parents who felt initial relief, “Oh, thank goodness my kid survived,” it turns into a nightmare experience years later.

So, we have the idea of preventing the mudslides by preventing the fire, but there’s more to this idea of “off-target” benefits than just measles, right?

Yes, vaccines are designed to stop the infection. Beyond this, we have made other observations, like the flu vaccine preventing heart attacks.  Turns out that a single flu vaccine has the same heart attack prevention power as taking a beta blocker every day for a year. That’s good news! Ask the question, Which is easier? 

That’s exactly the kind of description we need to turn the unhelpful term “off target benefit” into something motivational.

There’s more about the influenza vaccine. Sure, it prevents getting an infection, pneumonia, and hospitalization, and “there’s more!” The flu vaccine prevents the first crash that could turn into a chain reaction multi-car crash in your brain or heart, causing a stroke, a heart attack, or even dementia. Wait, what? How does it do that? Well, the mechanisms aren’t super clear, but you can easily imagine collateral damage from this little flu microbe attack. The fighting puts strain on your heart and on the delivery of oxygen to your brain, causing life-altering events.

And this system damage can be true for other vaccine-preventable diseases, right?

Indeed, more and more evidence is accumulating. Looking at people who got:

• pneumococcal vaccine; observing fewer heart attacks and living longer.
• flu vaccine; fewer heart attacks, and over 4 years, less dementia.
• shingles vaccine;  over seven years, less dementia.

COVID-19 vaccine benefits might surprise people. COVID-19 is a nasty disease. It shook up the whole world and killed a million Americans! It was a brand-new disease to us in 2020; it’s only been five years, and still we’re learning more about its short-term and long-term effects. All this is complicated by the social media and political landscape, with lots of information, misinformation, and disinformation about both the disease and the vaccines.

Turns out there’s some good news – similar to the flu vaccine, observing fewer heart attacks and strokes after the first shot, and even further reduction after a second dose.

So, again, that’s not why you chose vaccination – you didn’t get the shot to get rid of strokes and heart attacks — and yet it makes sense given how COVID infection damages your blood vessel lining, leading to more blood clots. And, when clots lodge in your brain vessels, they can cause strokes; and, lodging in your coronary arteries, can cause heart attacks.

Going into our discussion, I was assuming that vaccinations provided extra benefits because each vaccination was like a trip to the immune gym, a workout that made your body—in this case, your immune system—a bit stronger each time. But that doesn’t seem to be the mechanism in play here.

Good point. There are two main parts to our defenses, Innate and Acquired. We are all born with a built-in “Innate” immune system, our ability to notice “self” versus “non-self,” and then when it’s “non-self,” to question, “Are you a friend or a foe?”  In any population, there’s a spectrum of innate immunity, with some able to survive better than others. In truth, humans would have lost the war to microbes long ago if we didn’t have some variation in our natural immunity to fight them.

“Acquired” immune system is like going to the working out in the gym, practicing piano, or learning to swim. Vaccines are a way to learn, to practice, to get stronger, so when faced with the real-life situation, we do better. That’s the measure that we like to use in public health. How can we create stronger people and a safer community? How do we protect everyone, including the weaker ones in our community, and not just watch the roulette wheel spin to see who is lucky and will survive?

SUMMING UP

So, looking back at our goal, to get better at talking persuasively about immunizations, let’s review the options Dr. Hamstra has given us.

Seat belts.

Dr Hamstra has long used the “Vaccinations are like seat belts.”  Seatbelts don’t prevent accidents; they prevent injury from accidents. But now he suggests can take it a bit further, as evidence mounts that can even prevent some accidents. So, along with wearing a seat belt, you’re adding an accident-avoidance system.

Heart attack “accident” prevention

In promoting the flu vaccine, Dr. Hamstra points out that a single vaccine has heart attack prevention effectiveness similar to daily blood pressure medication. So what’s easier to do?

Once a year flu vaccine or daily beta blocker pill every day for a year?

Forest fires and War

Dr Hamstra used the wildfire and war analogies for measles, but they work more broadly.

“Measles infection can be compared to California fires — it just wipes out a lot of your natural biology, leaving you vulnerable when the rains come – your vegetation is missing, rains now cause floods and mud slides, things that wouldn’t have happened if the fires hadn’t burned everything down.”

“The measles infection can be compared to fighting a war. The fighting used up defense resources and caused a lot of damage. It takes time and effort to rebuild. For a while, you’re vulnerable, susceptible to another invasion or another attack.”

What we see is that vaccines aren’t just disease prevention; they’re damage prevention.

Going back to where we started, we aren’t advertising salesmen adding “off-target benefits,” but promoting a healthy lifestyle that includes vaccines, and we’re become increasingly aware of evidence of “value stacking” –  “but wait, there’s more” – more protection from heart attacks, from strokes, from dementia – and possibly more, more and more. Maybe there’s a place for immunization infomercials, after all.

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STATS OF THE MONTH

Immunization Serendipity:

The Changing American Family’s Living Arrangements

By Bill Davenhall, Geomedicine Analyst

The US Census Bureau recently released data on the American Household. While the Census Bureau counts people, one of the significant units of analysis is households, which contain most of the nation’s population.

The most recent data highlight the drastic swing in the living arrangements within households over the past half-century:

• In 1957, women married at 21.1 years vs 28.4 today; men married at 23.1 years, and now it’s 30.8.
• Fifty years ago, most couples (66%) in a household got married; today, only 47% do so.
• For families, 54% had their own children under 18 years of age in the household; now, only 39 live that way.
• Living alone in a household is now about 20%; in 1957, was 30%.

The bottom line is that there are more intergenerational relationships living in the same household than ever before. Surprised?

Multi-generation households are increasing, according to the US Census Bureau, and grandparents are more likely to be living in households occupied by other generational members. Many more adult children (18-24) remain living in the family household for more years than in 1975. Certain populations, like Asian and Hispanic families, bring different cultural norms into households that maintain “shared responsibilities” of the household regardless of the reasons for those arrangements (i.e., economic, cultural, and childcare).

Where then is the serendipity for immunization rates in all of this change?

Multigeneration households have stronger bonds across several generations, and grandparents are respected for their opinions on many issues. Very high percentages (79%) of multi-generational households claim strong family bonds, such as traditions and experiences that impact and boost household strengths. (The one place that appears not to be as supportive of multi-generation family living remains in the more rural areas of the nation – areas that already also have higher vaccine-hesitancy levels.) Despite the family economic structural issues that have created a more supportive immunization household environment, immunization advocates need to be alert to opportunities that generational and multicultural households present.

My takeaway here is this: be alert to the household “structural changes” that both culture, economics, and generational changes will have on the formation and growth of multigenerational households. As they say, “read the room” (community) you serve closely and experiment with ways to leverage the “serendipity” that the Census Bureau data suggests.

As always, I appreciate your 2nd opinions