As social creatures, humans reap tremendous benefits from organizing into societies and historically have developed elaborate strategies to facilitate group survival. Behavioral experiments demonstrate, for example, that Capuchin monkeys playing an exchange game will quit playing if they see another monkey getting a better deal,1 suggesting a highly developed sense of fairness among primates. In the experimental economics “ultimatum game,” two players divide a sum of money through an algorithm where the first player suggests a certain split, and the second player either agrees (whereupon the split is executed) or rejects it, at which point neither player gets anything. Although the rational move for the first player is to offer only a token fraction to the second player (and the second player to accept that fraction), in experimental testing, the deal only consummates if the first player offers nearly a 50/50 split because the second player will reject all other deals as unfair.2
In both of the aforementioned examples, subjects repeatedly reject the rational, “selfish” strategy, possibly because they are motivated by group rather than individual concerns. But as the group gets bigger, behavior becomes more complex. In closely related “cooperation” games, a group of individuals each decide in private how much to contribute to a common pot, which is then distributed among all participants. It is easy to see that for any single “round,” the greatest individual payoff is to contribute nothing and benefit from the largesse of others. It is also, however, immediately clear that subsequent rounds of this game will lead to more and more players contributing nothing as they realize that not everybody is contributing. In fact, in games with >5 trials, more than half of players will contribute nothing.3 That some players nonetheless continue to contribute is testament to the power of human group preservation behavior.4
In this issue of Anesthesia & Analgesia, Porteous et al.5 contribute an extensive, well-researched, and comprehensive review of the implications of vaccine-preventable diseases for health care workers. Porteous et al. cover diseases ranging from the well known (mumps and measles) to the less common but equally dangerous (diphtheria, polio, and meningococcus). The article will hopefully serve as a reference manual for anesthesiologists and other perioperative physicians.
Along with the nuts and bolts of transmission modes, isolation strategies, and disease epidemiology, Porteous et al. also paint a disturbing picture of a recent societal decline in vaccination rates. She notes that vaccination rates have fallen to <80% in some public schools and that the incidence of diseases such as measles and pertussis has been rising over the past decade. A chilling description of the 2014 measles outbreak at Disneyland is included that will unnerve any reader who has ever waited for a Disney ride. Porteous et al. note that of the 125 cases linked to the outbreak, 88% of patients were unvaccinated, 67% intentionally so. Many of the unvaccinated patients were from abroad, where vaccination rates are even lower than in the United States.
Given their extensive safety history, why are vaccination rates declining? The root causes are unclear, but rising concern over adverse effects of vaccines likely plays a role. One hypothesized cause for the rising incidence of autism was vaccines. This link has been unequivocally discredited. The one publication linking autism with vaccines has been exposed as fraudulent6–8 and subsequently retracted.9 Both extensive association studies10,11 and time trend correlations between vaccine use and autism diagnoses12 find no epidemiologic evidence for a causal association.
Although autism is not linked to vaccination, other idiosyncratic reactions to vaccines do occur. Because adverse events related to vaccines are rare and nonspecific, linking vaccines to specific adverse effects is difficult. To help catalogue these reactions, the Centers for Disease Control and Prevention maintains a Vaccine Adverse Event Reporting System, which is available online.13 Reported injuries include neuropathy, myoclonus, transverse myelitis, optic neuritis, arthritis, fibromyalgia, and of course anaphylaxis and Guillain-Barre syndrome. Unfortunately, accurate estimates of the likelihood of a causal link between these poorly understood diseases and vaccines do not exist. To forestall lawsuits that might lead to vaccine shortages, in 1988, the US Department of Justice created and currently maintains a $3 billion Vaccine Injury Compensation Fund, administered by the Department of Health and Human Services.14 In 2015, this fund paid out $8 million for vaccine-related claims.15
For health care workers, two challenges emerge. The first is to educate themselves and patients with respect to the personal and societal benefits of vaccines for preventing diseases that historically have wreaked havoc on people and society. With modern positive pressure ventilators and ready access to blood gas measurements, few today remember when rooms of negative pressure “iron lungs” kept polio patients alive, the Pco2 electrode had not yet been invented, and a presenting sign of excessive hypocarbia was tetany.16 Although now considered nuisances in the United States, Porteous et al. remind us that measles remains one of the leading causes of acquired blindness in the world. The teratogenicity of mumps and its predilection to spontaneous abortion is still clinically relevant today. Relatively high herd immunity thresholds for many viral infections (>95% for measles) put increased pressure on society to maintain high vaccination rates. That these established vaccines, which have reduced once-feared diseases to memories, are now actively avoided, making every case of measles-induced blindness or varicella pneumonitis more tragic. As perioperative physicians, anesthesiologists are frequently the gatekeepers for medical care. Anesthesiologists often identify diseases during preoperative evaluation.17 We can and should play a role in protecting the public health. We urge patients to stop smoking. We should also seize the teachable moment of perioperative preparation to educate our patients about the benefits of vaccines.
From a decision perspective, the rational approach for the individual deciding on vaccination is to weigh their share of the societal and personal benefit against the cost of a vaccine-related adverse event. With respect to standard vaccines with an established track record of safety and the potential to eradicate a clearly defined viral infection, that calculus unquestionably resolves in favor of vaccination. With vaccines that have less robust efficacy and possibly a higher adverse event risk such as the influenza vaccine,18 the calculation is a bit less clear. The effectiveness of the influenza vaccine varies, and recent 2015 estimates suggest a 6% to 29% effectiveness this influenza season,19 for example.
Unfortunately, estimating the personal risk from vaccines that must be created anew every year is difficult because safety testing is not possible, the mechanism by which such vaccines might cause injury is not clear, no test for susceptibility exists, and the tort system prevents epidemiologic analysis. Add in the difficulty of identifying prevented infections and estimating the societal cost of unchecked infection, and the resulting “fog of war” prevents ready calculation of risk/benefit ratios. Thus, decisions are driven by intuition, personal beliefs, and anecdotes, leading to considerable variability and strong opinions. The recent lawsuit by nurses at the Brigham & Women’s hospital protesting mandatory influenza vaccination20 demonstrates how even seasoned health care professionals might disagree as to the proper course.
Arguments centered on selfishness and/or potentially biased estimates serve only to Balkanize, an already divided society. Should fully healthy patients, pregnant individuals, or ones with existing autoimmune or neurologic disease be vaccinated against influenza? How safe is an influenza vaccine that must be created new every year and cannot be safety tested? What is the value of a mass influenza immunization program? Such questions cut right to the heart of the conflict between personal freedom and societal survival. The Centers for Disease Control and Prevention provides some answers,21 but it is heavily reliant on voluntary reporting systems for their data, a strategy that can be inaccurate.22
One thing is clear: even when the rational answer to cooperation games is to contribute nothing to the common good, a sizeable minority of humans will continue to do so anyway in deference to a societal goal. As Star Trek’s Spock has observed about human society, “Logic clearly dictates that the needs of the many outweigh the needs of the few…or the one.”23
Name: Avery Tung, MD, FCCM.
Contribution: This author prepared the manuscript and is the archival author.
Attestation: Avery Tung approved the final manuscript.
Dr. Avery Tung is the Section Editor for Critical Care, Resuscitation, and Trauma for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief for Anesthesia & Analgesia, and Dr. Tung was not involved in any way with the editorial process or decision.
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