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Taking action when recommendations breach public health


Medical practitioners and public health officials work within boundaries that, when crossed by others, can harm the people they are entrusted to protect. When these red lines are crossed, the medical and scientific community can — and should — speak out against it.

This process recently played out in Florida following a warning by the state’s Surgeon General that young adult men should not be vaccinated against Covid-19 by mRNA vaccines, the most commonly administered Covid-19 vaccine type.

Medicine and public health are not always clear and precise disciplines. Their practitioners must grapple with uncertainty in decision-making, especially when health-related recommendations may have serious consequences. Protecting public health rests in making decisions that depend on basic scientific foundations that include data collection, data analysis using validated approaches, peer review of findings, and consideration of feedback from experts.

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When this process breaks down, sometimes influenced by politics or a clamor for new treatments, faulty recommendations may follow. Think back to the misguided recommendations to treat Covid-19 with the antimalaria drug hydroxychloroquine or the animal deworming agent ivermectin, recommendations that were finally quashed by solid, peer-reviewed evidence.

Time and time again during the course of the Covid-19 pandemic, recommendations about public health measures based on data-driven approaches were either ignored or outright contradicted. Sometimes public health officials remained silent, while continuing to perform important work behind the scenes. Other times they pushed back against false narratives, triggering backlash that included personal threats against them or harassment. In comparison to sometimes bitter acrimony heard at public meetings during the pandemic, the pushback by those in medicine and public health is often not always visible. Rather, the approaches may focus on evaluating the science and sharing it as widely as possible. Unlike making official pronouncements, this process takes time.

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I am heartened to see the broad and strong responses from the medical and public health communities to several recommendations from the Florida Department of Health pertaining to Covid-19 vaccination. These recommendations differ markedly from standard Covid-19 control recommendations and have yet to be adopted by other states.

In March 2022, at a time when Covid-19 vaccines had been approved for children 12 years of age and older, Florida Surgeon General Joseph A. Ladapo recommended that healthy children not be vaccinated against Covid-19. The medical community, including the national American Academy of Pediatrics and its Florida chapter, publicly opposed this position. Their pushback was in part was based on the fact that about 40% of cases of severe Covid-19 in children that resulted in hospitalization or death occurred in children without underlying medical conditions. To date, there have been more than 1,500 Covid-related deaths in children, and Covid-19 has become a top-five cause of pediatric death, greatly in excess of flu-related deaths.

Three months later, the expert federal panel that advises the country on vaccines and vaccination recommended Covid-19 vaccination for children six months of age and older. Florida was the only state not to immediately follow this recommendation by ordering vaccine doses for the state. At that time, pediatricians in the state could not directly order Covid vaccines for this age group. The pediatric community publicly complained and requested that the state order vaccine doses so they could be made available to their patients. It eventually did, but Covid-19 vaccines are still not available for young children at county health departments.

The most recent across-the-red-line recommendation from Florida’s Surgeon General was that males between the ages of 18 and 39 years should not be vaccinated against Covid-19 using mRNA vaccines. This recommendation was based on an analysis that had self-described serious limitations, did not name the authors, and had not been subject to peer review before being posted on the Florida Department of Health website.

Experts in epidemiology at the University of Florida and the University of South Florida, to name a few, immediately provided open peer review, detailing serious concerns about the study and its conclusions. National scientific experts and organizations, including the American Association for the Advancement of Science, criticized not only the report but also questioned the process of making important public recommendations without scientific review of the report that led to the claims.

Does pushback from the medical and scientific community defuse unsound public health recommendations, or do the recommendations take hold and influence health care practice? Recent Covid-19 vaccination trend data for children show that vaccination rates for children between six months and four years of age in Florida are similar to other southern and many other states. Recognizing that vaccination rates in this recently vaccine-approved young age group is low, the increase in vaccination rates for this age group in Florida is similar to most other states. Data from Florida of young adults show that more than 75% of males between 18 and 49 years of age, have received at least one vaccine dose, and about 60% have completed the primary series. These findings are like those in the entire United States.

These observations show that what prevailed were not the poorly informed recommendations made by the Florida Department of Health, but the science-based recommendations made in response to them by pediatric groups and others focused on the health and well-being of children.

During the pandemic, medical professionals and public health experts faced challenges of making recommendations and decisions when answers were not always clear. Most tried to base their decisions on a process of following core scientific principles.

When the process is breached and officials cross the red line and endanger public health, those who believe in the foundation of science must take action. It may not always pay off and may be risky to those voicing opposition, but silence may be riskier for those they are entrusted to protect.

Scott A. Rivkees is a pediatrician, physician-scientist, professor of practice at Brown University School of Public Health, and the former State Surgeon General and Secretary of Health of Florida.





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