69 Doses...or Is It 53? Or Even Fewer?

Please note additional edits to this article, particularly those added after 2/3/16, with the publication of the new 2016 recommended schedule.
 
My deepest apologies to my readers for this rather long spell without any new posts. Work and real life both got rather too busy for me, and I just did not have the time or energy to write. It certainly isn't for a lack of topics. I have a couple that I would really like to get to, including at least one request. But to get back into the swing of things, I thought I'd start with something pretty easy.

The other day, I got into a discussion on Twitter with a naturopath by the name of Stephen M. Gibson. He caught my eye because he appeared to be using my post about package inserts to suggest that they are evidence that vaccines cause harm. Now, vaccine package inserts do list adverse reactions (i.e., something known to be caused by the product) discovered during clinical trials. They also include adverse events (i.e., something that occurs after using the product, but may or may not actually be caused by it) reported to the manufacturer after it has been put on the market. I tried to get Mr. Gibson to let me know which specific injuries he was concerned about. The best I got was him referring to Section 6 of the inserts (which, again, includes reports of things that are not necessarily caused by the vaccine) and that he's opposed to "Any. And every" bit listed in Section 6.

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But it wasn't his misuse of my post that really grabbed my attention and prompted this post. Rather, it was his claim that he has "read and studied the 69 vaccines package inserts in the Feds recommended list":

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Sixty-nine package inserts? Really? Where did he get this number?

As of this writing, the FDA lists 81 vaccines approved for us in the U.S. Now, that list includes vaccines that are no longer used (e.g., smallpox), as well as vaccines that are not on the recommended schedule (e.g., BCG, rabies, yellow fever). There are also multiple brands of vaccine (e.g., Fluarix and Fluvirin) that cover the same disease but are made by different manufacturers. Eliminating the obsolete vaccines, the ones not on the schedule, and the multiple variations of the same vaccine, the number is way below Gibson's claim of 69, meaning his claim that he read 69 package inserts is wrong.

Well, maybe his grammar is just bad and he missed an apostrophe, as in, "the 69 vaccines' package inserts". Since he mentioned the recommended list, I went to the CDC's 2015 Combined Recommended Immunization Schedule for Persons Aged 0 through 18 Years (PDF). At most, there are 13 vaccines recommended for the average child, which protect against 16 different diseases:

• Hepatitis B (HepB)
• Rotavirus (RV)
• Diphtheria, Tetanus, and acellular Pertussis (DTaP)
• Tetanus, Diphtheria, and acellular Pertussis (Tdap)
• Haemophilus influenzae type b (Hib)
• Pneumococcal Conjugate (PCV)
• Inactivated Poliovirus(IPV)
• Influenza (Flu)
• Measles, Mumps, Rubella (MMR)
• Varicella (VAR)
• Hepatitis A (HepA)
• Human Papillomavirus (HPV)
• Meningococcal (Men)

Maybe he meant the number of doses of those 13 vaccines? Let's see...nope, there are only 53 doses [Edited to Add (2/3/16): (or 52, depending on the rotavirus vaccine used)]:

• 3 doses of Hepatitis B (HepB)
• 3 doses of Rotavirus (RV) [Edited to Add (2/3/16): if RotaTeq used, 2 doses if Rotarix used]
• 5 doses of Diphtheria, Tetanus, and acellular Pertussis (DTaP)
• 1 dose of Tetanus, Diphtheria, and acellular Pertussis (Tdap)
• 3 doses of Haemophilus influenzae type b (Hib)
• 4 doses of Pneumococcal Conjugate (PCV)
• 4 doses of Inactivated Poliovirus(IPV)
• 19 doses of Influenza (Flu)
• 2 doses of Measles, Mumps, Rubella (MMR)
• 2 doses of Varicella (VAR)
• 2 doses of Hepatitis A (HepA)
• 3 doses of Human Papillomavirus (HPV)
• 2 doses of Meningococcal (Men)

I even  tweeted at him how I came up with the total number of doses (though I incorrectly listed 3 doses of Men at the time). Note that this list includes all of the boosters, despite his erroneous admonishment that I should include boosters. (As an aside, it should be noted that not all of these are required for school enrollment, so the number that kids have to get for school is even lower.)

Since I had shown the math that I used to arrive at my total number of doses, I asked Mr. Gibson to do the same. All he did was send me links to the recommended schedule I already referenced and an easy-to-read version of the same thing, which also adds up to 53 doses.

So where was he getting this mysterious figure of 69 doses by age 18? Where else but the anti-vaccine organization known as the National Vaccine Information Center. Specifically, he referenced a poster titled 49 DOSES OF 14 VACCINES BEFORE AGE 6? 69 DOSES OF 16 VACCINES BY AGE 18? (PDF, all-caps in the original). Here's a screen shot for your reference so you don't have to click through to their site:

Click to enlarge and find the dishonesty.

Take a look at that list and see if you can spot the dishonest tactic that the NVIC is using. Yes, they break out the DTaP, Tdap, and MMR vaccines into separate, individual doses. NVIC is adding 16 doses to the list.

Why is this dishonest? Well, when looking at the antigens alone, yes, there are 69 doses of antigen that a child receives. [Edited to Add (1/21/16): It should be noted that the overall antigen load in the vaccination schedule has been decreasing, even though the number of vaccines has increased, over the past 50 years.

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But as you can see, even going by antigens, the NVIC list is still misleading.]

But their poster implies that it's 69 doses of the complete vaccine (i.e., antigens plus all of the other stuff like stabilizers, liquid vehicle, etc.), especially given their footnote about vaccine ingredients. That's not the case. Let's look at it this way. There is a stand alone measles vaccine (e.g., India's M-Vac), but it isn't used in the U.S. M-Vac is given in a 0.5mL dose. In the U.S., the MMR vaccine is also a single 0.5mL dose, not a 1.5mL dose. You can see, then, why listing measles, mumps, and rubella out separately misleads people, and why the claim of 69 doses by age 18 is false.

And even 53 doses is a bit high. There are newer combination vaccines that mean even fewer injections. For example, Pediarix (PDF), given in a 3-dose series, combines the DTaP, HepB and IPV vaccines into one, meaning 6 fewer doses (3 doses of HepB and 3 doses of IPV), bringing the total doses a child receives down to 47. Or there's Pentacel (PDF), which is given in a 4-dose series and combines DTaP, Hib, and IPV. Using that would eliminate 7 doses from the total (3 doses of Hib and 4 doses of IPV), bringing the maximum doses received down to 46.

The next time you see someone claim that kids get 69 doses of vaccines by the time they're 18 years old, you can rest assured that they have either not done the math, simply taking the word of others for granted; misunderstood what they were counting; or they are lying. I'd recommend being charitable and assuming that they either haven't done the legwork to count things up or they simply misunderstood. But then, I tend to assume the best of people.

[Edited to Add (1/22/16): Mr. Gibson wasn't the only one parroting the 69 doses claim on Twitter. @VaxCalc did as well, posting this image:

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When I asked if they thought each time a child got a DTaP they got a 1.5mL dose, they responded, "Stick to "dose" as used in CDC schedule. Stop trying to obfuscate simple fact of 69 doses of 16 vaccines #Astroturf". Notice that the CDC schedule in VaxCalc's own image notes "1st Dose", "2nd Dose", etc., which adds up to 53, not 69.

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I do enjoy the irony of VaxCalc misleading by muddying the definition of "dose" while accusing me of obfuscation. Oh, and their apparent belief that "astroturf" just means "someone I disagree with saying saomething I don't understand".]

[Edited to Add (2/3/16): With the publication of the 2016 updated vaccination schedule, anti-vaccine folks are now claiming 71 doses or even 72 doses of vaccine. This is because the CDC has added the recently approved Meningococcal B vaccine to the schedule. However, what they do not note is that currently, the MenB vaccine is included only for those not at high risk, subject to individual clinical decision making, as well as for certain high-risk groups. It is not part of the standard recommendations for all children.]

I've written a follow-up to this post that I hope clears up some things. You can read it here.