Pitting national health care systems against one another

Here's some information about some of the diseases you have mentioned and their associated vaccines.

Hep A is not routinely offered in the UK because it's considered very low risk there. Even in the US, hep A is usually only something that gets introduced after someone visits a high incidence country. Likely, hep A's risk in the US is partly because we share a border with a high incidence country. Hep A is spread through contaminated food and water, and it takes an incredibly low amount of virus to cause disease in a person. When you get it as an adult, it can lead to some really serious liver complications, and many cases end up hospitalized. Likely, hep A in the UK is because they don't expect to get an influx of people coming in who are infected with hep A. By the way, currently, we are experiencing a hepatitis A outbreak of unprecendented scale and duration in San Diego, CA, and Michigan.

The point of the chickenpox vaccine is only partly to protect the kids. The vaccine will also mean that kids who are vaccinated against chickenpox won't get shingles. Also, when you get it as an adult, it is Bad Times.

Meningococcus vaccine isn't recommended until you're 12 years old. The CBA on it has been a bit back and forth, but this one is likely due to cultural things - meningococcus meningitis outbreaks are common when kids from all sorts of different places end up in one place (aka, college, frats (especially!!), team sports, spending a lot of time in close contact with others). Because the course of the disease is real quick (healthy to dead in less than 24 hours) and morbidity is so bad, it's pretty much recommended due to an abundance of caution. Two years ago, Santa Clara University had a case, and the state responded by mass vaccinating everyone on campus - something like 5,000 people in two days. Such an effort was hideously expensive, but still worth it to the state in terms of morbidity avoided.

Hep B is recommended because 1) there's no cure for it, and 2) having HBV increases your risk of liver cancer by an insane degree. Infection as a kid usually leads to lifetime infection in a carrier state (or to disease progression), whereas infection as an adult is less likely to lead to chronic illness. It's really common in East Asians and Africans, and HBV is also considered endemic in Latin American countries. Of your listed countries, the USA is also the most ethnically diverse. Basically, you're risking putting your kid at risk for liver cancer down the line. Also, HBV costs Medicare a shit ton of money every year in liver transplant/ liver cancer treatment costs.

For your point #2, those aren't "cultural" differences. It is literally the difference in your risk of getting the disease. TB is endemic and fairly high incidence in pretty much all of Asia. The US recommends against TB because we are a low incidence country and not vaccinating people makes it a whole lot easier for us to detect cases (case detection is through looking for immune reaction against TB. Having a vaccination means you have to either do a more involved test or a chest X-ray).

Every single disease on that list has significant morbidity associated with it, if not now then later in life.

The government also makes cars have seatbelts and airbags; is this because seatbelt and airbag manufacturers lobbied the government? How dare they make you pay for features you don't want! If you think you're never going to need that airbag, why should you pay for it?

As a reader of this site, I feel like you should understand that humans are very bad at evaluating small percentages. Under this lens, look at the risk of harm that the vaccination poses to your child, then look at the risk of harm that getting the disease may pose to your child.

The cost benefit analysis you should be doing is how much it will cost you to do this today versus how much pain it's going to cause your kid in the future.

I think this post underrates two general rationalist skills, plus some assorted empirical facts. First, the two skills.

1. Avoiding the fallacy of the one-sided wager. The post talks about cost-benefit analysis, but in a complete cost-benefit analysis one has to consider the risks of both choices under offer, not just one. The post takes specific notice of the default course of action's risks (money, tears, side effects) but focuses less on the risks of the alternative (e.g. toddlers winding up in the ER because they're shitting themselves half to death from rotavirus).

2. Trying to look things up. I'll pick this point up briefly below.

The rest of this comment is going to be scattershot, as it just runs through relevant facts I was inspired to check or dig up by different bits of the post.

I grew up in the US in the 80s and I don't remember getting nearly this many. Is my memory faulty?

Probably not, there's a simpler alternative explanation: adults remember basically nothing from before age 3 or so. However, we don't even need that explanation, because...

I'm pretty sure it was more like 12 back in those days.

...the CDC actually did recommend fewer vaccines in the 1980s (via). Though this wouldn't address whatever local or state-level vaccine program you might've also experienced as a kid.

Is this all really necessary? Nobody likes getting shots, especially not children. What changed, anyway?

Scientists and clinicians developed and tested newer vaccines and better vaccines. Seriously! (I think this is an example of how people, even very educated people, tend to not understand on a gut level how much of microbiology's progress was made just in the past 40 years.)

The CDC's 1989 vaccination schedule and current schedule for normal children have only 3 vaccines in common: DTP/DTaP, HbCV/Hib, and MMR. That leaves 7 vaccines which appear on the current schedule but not the 1989 schedule. I looked each of the 7 up online and discovered the following.

• A patent on hepatitis B vaccine was filed in 1969, but the earliest actual vaccine appears to have come only in the 1970s. It was shown effective in 1980 and made available in 1981, but the vaccine wasn't ideal for mass vaccination because it came directly from carriers' purified blood and was hard to mass produce. A superior recombinant vaccine came along only in 1986, the first of its kind for humans.

• Rotavirus vaccines didn't even get to the point of testing until the 1980s, and the first publicly introduced vaccine arrived only in 1998. And was then promptly withdrawn due to concern over a potential side effect — clinicians & manufacturers do keep an eye open for side effects!

• Pneumococcal vaccines have been tested in people for about a century but were relatively ineffective and poorly understood, and their popularity waned with the rise of penicillin. Modern tests began again in 1968 and continued into the 1970s, resulting in US approval for a new vaccine in 1977. However, that vaccine covered only 14 variants of pneumococcus; an improved 23-variant version "covering about 87% of bacteremic pnemuococcal disease in the US" came out in 1983 and was recommended for routine vaccination only in 1984 (and then just in old adults).

• Inactivated poliovirus wasn't new (Salk famously developed it in the 1950s) but in the current CDC schedule it merely replaces the oral polio vaccine (OPV) used in the 1980s. The inactivated poliovirus vaccine is safer than the OPV in that children who receive the OPV can crap the live, active virus back out.

• Influenza vaccines are even older, dating to the 1930s.

• The first varicella vaccine was developed in Japan in the early 1970s, but its safety and worthiness were controversial. Clinical trials took place in the 1980s and the vaccine was licensed for use in Japan in 1986. The US followed suit in 1995.

• Hepatitis A vaccine went on the market in the early 1990s. Based on playing with Google Scholar, I think the key human studies were done in the late 1980s and early 1990s.

So we have a mundane explanation for most of the newly introduced vaccines for healthy young children; today's vaccines weren't ready before the '80s.

Now, I'm not an expert on immunology or epidemiology so I expect diving into the literature isn't going to be fruitful; I won't be able to ante up decades of education and experience fast enough.

Don't do yourself down! A lot of material written by clinicians & researchers is out there, some of it deliberately targeted to laypeople, and you can often get some understanding even of technical material just by reading, recalling high-school biology, doing arithmetic, and looking things up in medical dictionaries. You won't learn everything, but if the topic is important to you you can discover a lot by spending a few weekends with Google. (There are topics it's hard to get a hold on as a layperson, but it's hard to know whether a topic's that difficult without trying to get a hold on it.)

Here's how many shots each nation's health care system recommends by the time children turn 5.

37 US

25 UK

I thought I'd take a closer look at these two countries (they're both Anglophone, easiest to check). I get somewhat different numbers: 32 or 33 for the US/CDC (count the yellow boxes, remembering to count the annual flu virus 5 times) and 19 for the UK/NHS (only 4 anti-flu injections here; we don't start them until age 2).

Also, while there's a clear UK-US difference in the number of injections, it's exaggerated by the UK lumping multiple vaccines together into one injection. The UK bundles the DTP, polio vaccine, Hib and hepatitis B vaccines; if I broke those out separately I'd get 29 injections instead of just 19 (and then I'd get 30 if I split the combined Hib/MenC vaccine). The numbers of distinct exposures to microbes are similar in the two countries.

When it comes to cultural and environment differences I have a hard time imagining that the orthodoxy varies because Hep A is a much bigger deal in the US. I presume the calculus changes based on your geographic neighbors, but is it a meaningful difference?

Probably the prevalence of hepatitis A in the US itself plays a bigger role. Trying to summarize hepatitis A's prevalence in different countries is a bit of a pain, because prevalence varies a lot by age and cohort as well as place, but I did find a couple of kinda representative studies of the prevalence of hep. A antibodies in the US and UK. Immediately before (1988-1994) vaccine licensing a national survey found a prevalence of 32% in the US, while a nationwide UK study got a prevalence of 12% in unvaccinated individuals around 2002.

On the flip side of this argument: so what if we vaccinate kids against more diseases than other countries? Well, they're not free. [...] Those other nations (presumably) ran cost-benefit analyses too and came to different conclusions. It would be nice if each country showed their work.

At least 3 of the 5 countries you discuss have shown work. See the US's CDC, the UK's Joint Committee on Vaccination and Immunisation, and Germany's Standing Vaccination Committee at its Robert Koch Institute. Granted, I couldn't find any dedicated webpages for Denmark or Sweden in a few minutes of searching, but that may be due to my non-knowledge of Danish & Swedish.

It seems like you're trying to analyze the wrong things. Second-guessing motives for recommendations that apply to large variant populations is a losing game, and you missed what may be a fairly large reason: prevalence of the disease in that region. In any case, ignore politics and look at expected value and risks of each option AS IT APPLIES TO YOU.

Where will you be living/visiting? What is the actual incidence and cost of these diseases, and what are the network effects of many people being immunized vs not? I worry that you think the biggest cost of chicken pox is staying home with a sick kid - the actual biggest risk is that the kid WON'T get it as a kid (because all the neighbors and other kids are immunized), and will instead get it as an adult when it can be very serious.

Shots aren't terribly expensive, the pain of the stick is fleeting, and the chance of serious side-effects is quite low. Compare that to the pain and probability of the disease, and I'd generally say take all you can get. My default would be the union of recommendations for anywhere I expect the kid to visit, rather than the intersection.

"When it comes to needles to stick my new kiddo with, I'm not really being persuaded to do more than the intersection of vaccinations between similar nations."

You don't know enough to decide this. What is "similar" (climate, culture, disease spectrum?) Do you know the history of their immunization laws?

Seems to me you first decided this is an icky procedure, and it hurts your kid, and you feel protective. Then you went looking for reasons not to do it. Immunization has a free-rider aspect, because of herd immunity. So you may well get away with it, in terms of your kid's health, but "people like you" (defectors in PD) are a problem.

If you are an evil pharma-corp, vaccines are a terrible way to be evil.

C/D calculations in public health are real, but this is one of those things where the only way to be effective is not break the phalanx formation.

Is this all really necessary?

Necessary is a bad word. The core question is what happens to be the highest utility.

In the US we also recommend: Hep A, Hep B, Rotavirus, Meningococcus, Varicella, and yearly flu shots (for babies and children).

Meningococcus, Rotavirus and Varicella also seems to be on the schedule in Germany. The first three I Googled.

It would be nice if each country showed their work.

Every country does has a commission that argues their decisions. From your perspective the problem is likely that the German documents are in German, the Danish in Danish and the Swedish in Swedish.