Request for advice

[vyvyanx]

When I was a child I never had the BCG vaccination against TB. (I've no idea why not; I guess it was a mistake.) A while ago I discovered this fact through talking to people of a similar age, and since TB seemed to be somewhat on the increase in this country at the time, I went to my doctor to ask for immunisation. She said that a) it was unnecessary since I was not in a high-risk group e.g. working with homeless people; b) it did not provide reliable individual protection, only public health benefits through reducing overall incidence, so individual vaccinations were a waste of time; c) they didn't have any TB vaccine available at the time anyway. So I went away, somewhat reassured.

At lnr's party on Saturday, I got talking to a couple of people who thought it was utterly terrible that I had never been vaccinated against TB, and I must be presenting a serious danger to the population, and should rush out and get myself vaccinated at once. They thought my former doctor was plain wrong, and anyway the incidence of TB in this country had risen since I spoke to her, and I should go back and demand vaccination at once.

What do people here think, especially those with medical expertise? A websearch is not very helpful to me: the NHS explains how everyone is given the BCG at ages 10 and 14, but older people can be vaccinated if they are at risk. I have found several references to the (slowly) rising incidence of TB in the UK, and especially to the increased incidence of drug-resistant TB worldwide. I don't wish to waste my doctor's time by going and asking the same question I asked a few years ago, if the answer is likely to be the same. But neither do I wish to be a menace to society through lack of vaccination!

Comments

[devalmont.livejournal.com]

Her point about it only being a general prevention of overall incidence seems to display some rather false logic, as how can the overall protection of the population be increased if it doesn't benefit the individual to be inoculated? It smacks of budgeting to me, and I would request that you be immunised. They can advise you against it, but if you request it they are at an obligation to provide you with the protection that the rest of us have anyway.

[zotz]

It's much less trouble to do large batches. Presumably the gain from doing one person isn't a good use of time or other resources. After all, getting or keeping individual doses or small batches of vaccine will also be more expensive.

[devalmont.livejournal.com]

This is very true, but isn't it within vyvyan's rights to receive inoculation for TB, if she should have received it when at school? Or does one waive the right if it's not done as a batch?
I'm not well up on this kind of thing, I'm afraid, too long as a filthy Thatcherite private healthcare type ;-)

[zotz]

Rights?

I'm not sure that's a useful way to think about it. The NHS (and indeed the government - and, indeed, society as a whole) functions on finite resources and has to decide what those resources are best applied to. WRT vaccination, a policy is decided on which those responsible believe is the best use of the available resources, and this is implemented by the rest of the Health Service.

We could take the view that we pay our taxes to individually have the best protection available, but a wider view is that the incidence and risk of these diseases should be lowered as much as possible, even if it means that those least likely to be exposed to it are otherwise unprotected, because the best measure of success is not the vaccination rate but the maintenance of a low rate of active TB in society at large.

[vyvyan.livejournal.com]

So do you think I should go back to my doctor and ask about this again? Other people seem to be accusing me of trying to get a "free ride" out of other people's vaccination, or playing "defect" in a sort of Prisoner's Dilemma, or doing the selfish thing rather than the moral thing. But I have no objection to being vaccinated - indeed I would like to be vaccinated - but only if there is actually some net benefit to society through me doing it. If I'm just going to waste NHS time and resources which would be better spent elsewhere, surely the more selfish, immoral thing to do would be to demand personal vaccination! Besides, I'm not aware I'm actually entitled to demand any NHS service which isn't medically recommended, so it may not actually be possible to get this vaccination without lying to my doctor about my personal risk of infection - and that would certainly seem immoral to me.

[zotz]

I wouldn't say it was worth going for on its own, but if you're ever there anyway you might as well ask again.

[antinomy.livejournal.com]

Reasons for being vaccinated at your age would be if you started doing high-risk work (as you described, or in research, say, or if you decided to work in an abbatoir, or similar) or if you were travelling places like the Indian subcontinent, or Africa, or the former USSR, where the incidence is much much higher. Equally, if you were going to live in close proximity to many other people, for whatever reason. TB generally needs protracted close contact to be infectious to healthy adults.

The individual efficacy of the BCG isn't terribly good, but like all population-level public health measures, uptake has to be high for them to work, (especially if efficacy isn't high as in this case). So, selfishly you should not bother unless your risk changes, but arguably you should take the needle for the good of society. Kinda depends how you feel about such things...

I didn't get a BCG for many years because I was advised similarly to you at the time that my school was recommending people had them. Then, when I went to boarding school, they jabbed me because it was policy. As I never reacted to the vaccine, I suspect it didn't take, but haven't bothered to go back and have it repeated, or have the skin test repeated. If I ended up working in veterinary public health of some sort, I would probably have to.

[angoel.livejournal.com]

When one person has TB, they'll pass it on to on average X other people before they get better. If X is greater than one, you get epidemics, where there's a geometric increase in the number of people who have the illness. These end because after you've had the illness, you're not likely to catch it again, so after a time enough of the population are sufficiently immune that X goes back below one.

Vaccinations help to stop epedemics (and similarly decrease the amount of disease around) by decreasing the chance of picking up TB, pushing X below one. They don't protect so much by making it impossible for you to pick up a disease, but by making it harder for anyone to get it, so not only is it harder for you to get it, but it's less likely that there's anyone to pass it on to you. This means that people opting out of vaccinations is somewhat of a prisoners dilemma thing - it's marginally safer provided sufficient other people don't defect - if they do than everyone's worse off.

Regarding your status on defection >;-), the position's marginal. It's unlikely to have a significant effect either way, and it may well be more optimal to spend NHS resources elsewhere. On the other hand, vaccination, in my opinion, is the honest side to be on. Up to you.

[antinomy.livejournal.com]

When one person has TB, they'll pass it on to on average X other people before they get better. If X is greater than one, you get epidemics, where there's a geometric increase in the number of people who have the illness. These end because after you've had the illness, you're not likely to catch it again, so after a time enough of the population are sufficiently immune that X goes back below one.

Except in TB, you don't recover, you become chronically infected but only start shedding in your old age when you pass the disease onto your grandchildren, which is what makes it such a pervasive and difficult disease to erradcate.

[hairyears.livejournal.com]

Bits of this are right, and bits of it aren't. Most people write about epidemiology from the perspective of 'epidemics', and pay very little attention to continuing low levels of a disease. These can exist for a variety of reasons - a widely-distributed subpopulation of susceptible individuals, symptomless carriers, persistent spores etc. The commonest cause is localised 'at-risk' populations or 'reservoirs' of patients where a small group of people has a self-sustaining level of infection. Think of AIDS and intravenous drug users.

For TB in the UK these are:

• closed communities with strong links to the Indian subcontinent (not strictly self-sustaining but dynamically stable due to continuous replenishment);
• Slum dwellers (bits of the hostel system are like the Bronx 'lung block');
• Concentrated populations of substance abusers, including chronic alcoholics, and especially those gathered in overcrowded squats and derelict buildings
.

These groups are the source of a regular stream of 'isolated cases' in chains of infection that eventually fizzle out in the general population.

Everybody who catches TB in one of those chains, catches TB off of someone who wasn't vaccinated, or someone who was and got no benefit from the vaccine (in the UK that's about 25% overall but in some areas, probably with poor housing and public health, it can be more than half).

If you get TB, you might never know: just another flu-like thingy that you've soon forgotten, and you probably fought off the infection completely in a week. Most healthy people do. But you were 'shedding' infectious particles all that time. If you're one of the unlucky few who get a dormant infection, you definitely can become infectious again, any time you're immune system takes a knock and sometimes for no reason we'll ever know.

Yes the odds are getting TB in Britain are very low indeed. You, personally, don't particularly need the vaccine because the chain of infection will always fizzle out if more than 40% of the population are immune. The stable equilibrium of low-level prevalence will remain so low (about 5 cases per 100,000 in the general population) that you needn't bother, because other people have done their bit.

Setting aside the moral issues in this approach, there remains a practical problem with a 'free-rider' strategy: the risk that too many people will do the same. This proved a very harsh lesson indeed to parents who denied their children the pertussis (whooping cough) vaccine, with the result that vaccinations in the North-West dropped below 75% coverage in the early 1980's, allowing the disease to persist at a low but self-sustaining level in the general population. Most, of course, still got away scot free, and will loudly tell you that the risks of the vaccine outweigh its potential benefits (below 75% coverage, they probably don't, but there is very little independent research and none of it is available online).

The moral issue is pretty simple: can I take a small risk for myself, knowing that I'm taking the same risk for other people without asking them? And what if those other people aren't 'free riders', knowingly taking the same risk that I do? Every few days you'll come into contact with people who do not develop an effective immune response with the current vaccines.

You can find out what kind of person you are, by asking if you're bothered more by the thought of catching it from them, or giving it to them. Or by discovering that you're not bothered either way.

And yes, there's a hectoring tone to this reply, and maybe even a note of accusation; but face it, no-one here is a spectator and it's a life and death issue. As in, people die from this, no matter what rhetorical tricks we use in our debate.

[deliberateblank.livejournal.com]

I got talking to a couple of people who thought it was utterly terrible that I had never been vaccinated against TB

They're probably just jealous because they've got huge fuckoff scars on their arms and you haven't.

[teleute.livejournal.com]

Having read all this down to the bottom, I discovered what I wanted to know: this is the one that gives you the nasty scar. I don't have it either (I believe that this was the vaccine where I point blank refused to be shot with a needle, passed out nearly threw up and they carted me off. I was 14 at the time, is that about the right age?) When I was talking to my UK doctor about coming out to America, he said that it didn't matter for me, since hardly anyone in the US is vaccinated against TB. Does that (combined with the info above) mean that I should get vaccinated anyway, to help protect me from the possibility of an epidemic in the (mostly unvaccinated) US?