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Parents Who Don't Vaccinate Kids Tend To Be Affluent, Better Educated (go.com)

schwit1 quotes ABC News: Vaccines are universally backed by respected scientists and federal agencies, but that isn't enough to convince every parent to vaccinate their children. The decision to fly in the face of near universal scientific opinion doesn't come as a result of a lack of intellect, however, as experts who have studied vaccines and immunology acknowledge that many parents who don't vaccinate their children are well-educated. They also appear to be the victims of a widespread misinformation campaign, the experts said.

Daniel Salmon, who is the director of the Institute of Vaccine Safety at Johns Hopkins University, said that existing research suggests that there are some common attributes that many parents who choose not to vaccinate their children share. "They tend to be better educated. They tend to be white, and they tend to be higher income. They tend to have larger families and they tend to use complementary and alternative medicine like chiropractors and naturopaths," Salmon said.

Salman also says outbreaks typically start when an American returns from a visit to Europe, where there are much higher rates of measles than in the U.S. But lower vaccination rates help it spread.

One study in August reported Russian trolls "seem to be using vaccination as a wedge issue, promoting discord in American society," though their campaign on Twitter failed to gain traction.

"I blame Amazon Prime," writes long-time Slashdot reader destinyland. "That 'misinformation' they're talking about is the pseudoscience documentary Vaxxed -- and Amazon is one of the top site's pushing it. The movie is not only free for all Prime members -- Amazon's actually featuring it on the front page showing free-with-Prime movies."

46 of 411 comments (clear)

  1. One-eyed among the blind. by Anonymous Coward · · Score: 3, Insightful

    This is a pattern that I recognized. There's a class of people that are smarter than the US average, yet still rather stupid and arrogantly over-confident from an actually smart point of view.

    E.g. Randall Munroe of xkcd or Ricky Gervais are famous examples.

    They simply LOOK and ACT smart, but they aren't really that smart. They're just not utter and complete morons.

    1. Re: One-eyed among the blind. by bobstreo · · Score: 4, Insightful

      There's plenty of issues people have with vaccines that are based in science, often from the vaccine companies themselves. It's a parent's choice to teach a child their culture, just the same to vaccinate or not... you cant shove a lifestyle onto anyone. One way or another...

      Unless you're planning on home schooling them. No proof of vaccination, no public schools or most colleges for you.

    2. Re:One-eyed among the blind. by bill_mcgonigle · · Score: 5, Interesting

      You might be referring to the Dunning-Kruger effect. Like somebody who is top of their game in field A assumes their knowledge is sufficient in field B.

      They may also be bad at stats and be completely unaware of it.

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    3. Re: One-eyed among the blind. by Rei · · Score: 5, Insightful

      Antivaxxer kids are like dark humour - they never get old.

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    4. Re:One-eyed among the blind. by PolygamousRanchKid+ · · Score: 4, Insightful

      There's a class of people that are smarter than the US average,

      The title says "better educated" . . . not "smarter".

      Lots of folks are educated way beyond their intelligence.

      If your family is affluent enough to send you to Andover, Exeter or St Paul's . . . you're better educated.

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    5. Re: One-eyed among the blind. by Anonymous Coward · · Score: 5, Insightful

      Found one of the educated ones.

      Vaccination is not a lifestyle choice, regardless of what the morons spouting anti-vaccination rumors say.

      Vaccination is a medical choice. You either assist society by exterminating destructive diseases, or you literally empower your dumb-by-extension children to accidentally infect and kill children with responsible parents, who are too young to be vaccinated.

      Does that mean you need to get every vaccine for your child? No. Chicken pox has a vaccine these days and it's not on the same tier as other diseases (though why risk it?). Measles though? That stuff will kill your child and, if not them, then your neighbor's younger child who cannot get it yet. Thanks to people making the decisions that you're describing, combined with immigrants coming from places without the vaccine, Washington State has had to declare a state of emergency.

      I actually agree that you should be free to avoid any and all vaccinations because that's what freedom allows. But that doesn't mean that you should be afforded the tax payer-assisted opportunity to then put your child into contact with everyone else's children in publicly funded places, like public school. And it definitely doesn't mean that when your child does get those diseases that the government should assist you financially to get through it.

    6. Re: One-eyed among the blind. by bobstreo · · Score: 4, Insightful

      So then they're off the hook for school taxes, right?

      LOL no. School taxes are based on owning property regardless of how many children you have in the household.

      The real value would be having 10 kids, same price as one.

    7. Re: One-eyed among the blind. by Anonymous Coward · · Score: 5, Insightful

      If you look at the pros and cons and there is no medical contraindication, but you still decide that your kids should not be vaccinated, then you can't blame it on science, you're just being a dumbass. This is not a lifestyle choice, the same way giving your children cigarettes is not a lifestyle choice. That's endangering a person in your care, and in the case of antivaxxers, many others too. If you and your kids are serious threat to the well-being of a population, that population is morally justified to defend against you. People are afflicted with lifelong handicaps due to that sheer idiocy. Some even die. This is not tolerable. People who do not have their kids vaccinated should be banned from medical insurance.

    8. Re: One-eyed among the blind. by LifesABeach · · Score: 2

      I look at non vaccinating folks as very proud that they're willing to watch their children be damaged or killed. Bless their hearts.

    9. Re:One-eyed among the blind. by hey! · · Score: 5, Interesting

      I have a younger relative who's an anti-vaxxer, and she has a master's degree in school counseling. She's not a bad person, in fact she's a good person but with overblown, romantic disposition that blinds her to her own folly on the issue.

      Here's what I think happened. After Vietnam, and revelations about cigarette companies lying about lung cancer, and the Tuskegee Syphilis Experiment, we've done a good job teaching people to be wary of authority and corporate power. We haven't, however, done such a great job in giving them something *other* than trust in authority to fall back on. We haven't taught them to be skeptical.

      Disbelieving a traditional authority figure and then putting your faith in an alternative authority is not skepticism. Treating every question of fact as if it were a matter of opinion isn't skepticism either. Both these things kinds of weak-tea skepticism are just alternative forms of credulity.

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    10. Re: One-eyed among the blind. by Anonymous Coward · · Score: 2, Insightful

      No, they should be banned from medical insurance because they're taking the benefits of the group for themselves, but refuse to be part of the group when it comes to fighting epidemics. If they were only endangering themselves, it would not be an adequate reaction, but they're not and it would be.

    11. Re: One-eyed among the blind. by xenog · · Score: 2

      I would expect skydiving accidents to rarely require much in the way of healthcare.

    12. Re: One-eyed among the blind. by queequeg1 · · Score: 5, Insightful

      Good point. I live in a somewhat rural part of Clark County, WA (where the recent measles outbreak is taking place) and know a fair number of parents who are adamantly against vaccines. They tend to fall into one of two camps. First, there is a more religious group (Apostolic Lutherans being a significant portion but a number from a variety of Christian sects) that homeschools their kids (although even homeschooled kids will have a number of interactions with regularly schooled children). Relatively few of them will go to college. Instead, they generally move into a skilled trade after getting their GEDs. These people have generally been living in the area for generations and I seriously doubt that any level of education will change their minds. Closing them off from public schools/colleges will have little effect. I read their posts on the community Facebook pages and the shortsightedness and irresponsibility makes my mind reel. While they don't like measles, the prospect of infection isn't nearly enough to make them change their minds. I question whether anything more serious would. Second, there is a large community of first generation Russian and Ukrainian immigrants, many of whom tend to look with suspicion at anything any government asks them to do. I suspect this community will come around after a generation, if not sooner, since this group, although wary of government, tends to be more pragmatic and some of the measles infections have occurred in Slavic community centers and private schools.

    13. Re:One-eyed among the blind. by Anonymous Coward · · Score: 5, Informative

      because there are some people that can't be vaccinated for various reasons and people who could be but choose not to put them at risk, kids who have certain disorders, newborns, women who are pregnant who may not be as well protected by their own childhood vaccinations because of changes in body chemistry, elderly people, etc, etc, etc

      to address what some anti-vaxxers try to rely on, yes there is a herd immunity, but we rely on it for those that legitimately can't be vaccinated and not just those that choose not to because they are morons, besides the fact that if we get enough morons, then the herd immunity disappears anyway

    14. Re:One-eyed among the blind. by hey! · · Score: 4, Informative

      The anti-vaxx conspiracy theory is that Big Pharma have co-opted scientists.

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    15. Re:One-eyed among the blind. by sjames · · Score: 4, Insightful

      The problem is "authorities" also told us to give up butter in favor of trans-fat laden margarine and keeps alternately telling us eggs are good and eggs are of the devil. Then the people who brought out that smoking is harmful and then somewhat exaggerated the claims for 2nd hand smoke have started going off about 3rd and even 4th hand smoke (I'm not kidding).

      All of that really has left a vacuum that is now being filled by cranks and quacks.

    16. Re: One-eyed among the blind. by Hognoxious · · Score: 2

      Singles vaccine? Is that the one that makes it less likely your children will get diseases?

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    17. Re: One-eyed among the blind. by Hognoxious · · Score: 2

      Looks like cayenne8 forgot his password.

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    18. Re:One-eyed among the blind. by EvilSS · · Score: 2

      But why should you care if they don't vaccinate as long as you vaccinate? Isn't that what vaccines are for?

      Vaccines are not 100% effective across the population. For example, of the children who die from flu each year, around 20% were properly vaccinated. Additionally, there are populations who cannot, for valid medical reasons, be vaccinated. Thus, it's important that as many people who can be vaccinated are, to provide protection to those who cannot be vaccinated, or for whom a vaccine may not be effective.

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    19. Re:One-eyed among the blind. by LostMyAccount · · Score: 2

      I wonder how many of the anti-vaxxers are "cheaters" in other spheres of their life. I have this idea that anti-vaxxers believe (or know) the actual odds of their kid developing an immunizable illness are very low, but they think it will give them an advantage to not expose them to a vaccine -- it's the best of both words, no autism/vaccine risk and the disease risk is very low.

      It's like just another sociopathic behavior trait common among the well-educated/wealthy. They probably cheat on their taxes, maybe on their spouses, and are generally willing to break the rules if they can get away with it and get something out of it.

    20. Re:One-eyed among the blind. by q_e_t · · Score: 3, Informative

      In general the advice over the last 70 years with regards to diet, exercise and smoking has been pretty consistent. Where there are adjustments to the overall pretty consistent message it gets blown out of all proportion. Plus people tend to suggest that the message is black-and-white (give up butter) when the actual advice was to reduce saturated fat overall and replace with with monounsaturated vegetable fats, not margarine. Sometimes examples like noting that butter contains a lot of saturated fat is mentioned when people are asked for examples, and the actual advice seems to be lost by turning the nuanced advice into the headline 'Butter is now bad!'.

      In terms of exaggerated risk that is often due to the misunderstanding between risk, prevalence and lifetime risk. Clinicians probably don't help matters, but again it's mostly the media not understanding the science.

  2. Educated? by Anonymous Coward · · Score: 5, Insightful

    I don't think educated the word that you're looking for. How about uselessly credentialed?

    1. Re:Educated? by owlaf · · Score: 2

      I add on is my experience with a friend I lost touch with, well because you could say he is losing touch with reality. He really went done the rabbit hole of vaccines causing autism. He spent a lot time on facebook groups, and thought at one point the gov't was kicking him out of the groups. I tried to calm him down by suggesting just stay off of there for a while. His response was "I go to work and come home, that is all I have outside of work". I got the feel he didn't believe his own BS, but it gave him purpose. He went to mediocre college and has a office job now he doesn't care for. I thought about the reason for being kicked out of fb groups, and I am pretty sure it is his ex-wife. He met her through those groups. She went back to England (he is from the mid-west) to get her things, and found an argument to stay there and get a divorce. She seems nice, but he has seen her mean streak. He became involved with the fb groups because he thought food allergies, and she has had somewhat similar issues. She introduced the idea of vaccines causing autism to him

    2. Re:Educated? by Solandri · · Score: 2

      I think everyone's jumping on the wrong correlation here. Affluence is probably the key factor here, not education. These are people who can afford the extra medical expenses for their kids if they do happen to get sick. So they don't vaccinate them for whatever reason, knowing that they can pay for their treatment if they happen to lose that die roll. A less wealthy person might be wary of vaccination, but knows they can't afford to have their kids get sick, so that overrides their aversion and they go ahead and get their kids vaccinated. (Note that this implies the rate of vaccination would be lower if cost were not a factor, meaning that our education about the benefit of vaccination is even more of a failure than vaccination percentages would suggest.)

      The correlation with education is probably just coincidental. Both A (don't vaccinate) and B (higher education) are caused by C (more affluent).

    3. Re:Educated? by robot5x · · Score: 2

      I agree, affluence is definitely the key factor here. Not only because of excellent point in above post, but also because of the constant rush to be able to do things differently, as some kind of weird status symbol, to demonstrate affluence to others, probably with the side goal of appearing to be more knowledgeable.

      "Yeah I could have just bought a [averagely efficient and cost effective car model] but I did my own research and really this hand-crafted, 2-seater, avocado-powered scooter is the best thing for my family. It's Goop-certified, you guys should really think about getting one."

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  3. Not really by PPH · · Score: 3, Interesting

    They also appear to be the victims of a widespread misinformation campaign, the experts said.

    I suppose this could be a case of 'Never attribute to malice that which can be explained by stupidity.' But I'm going to go out on a limb and call BS. The affluent expect your little snot-dribblers to get vaccinated. No matter how small the risk. Just so their precious ones can benefit from herd immunity.

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    1. Re:Not really by Sique · · Score: 5, Insightful

      Because your freedom ends when it endangers my life.

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  4. Study must be deeply flawed by Rick+Schumann · · Score: 5, Insightful

    Either this 'study' is deeply flawed, or it's actually the product of the Russian trolls it speaks of, since this makes precisely zero sense, someone not vaccinating their kids against common diseases is among the obvious definitions of 'unintelligent'. Don't really give a damn what anyone thinks of what I just said, either, so don't bother.

    1. Re:Study must be deeply flawed by Sique · · Score: 4, Insightful
      We have a typical case of "only the dangers I see are important".

      As measles and polio and rubella and all the other illnesses we vax again are (thanks to the vaccination) no longer in plain sight, people tend to underestimate their risk. As we easily can imagine the piercing hurting the child, the wound becoming infected, the child misreacting on the vaccines and so on, we tend to overestimate their risk. Thus we want to protect the child against the perceived danger and not against the real danger.

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    2. Re:Study must be deeply flawed by gtall · · Score: 3, Insightful

      No it isn't an obvious definition of unintelligent. As someone above mentioned, it could easily result from the affluent thinking the proles need the vaccines so they can surf the herd-immunity. If anything, it is self-absorbed selfish behavior.

  5. Huh? by Actually,+I+do+RTFA · · Score: 4, Insightful

    Randall Munroe seems fairly well educated in technical areas. Did I miss something? And, from my understanding,he's open and upfront that his comics aren't based just on his knowledge but that he has to do research fro them.

    And I never heard anyone claim Ricky Gervais is particularly smart. Maybe you were confused by his accent into thinking people thought he was smart?/p:

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  6. intellect != well educated. by Anonymous Coward · · Score: 4, Interesting

    The article claims that:

    The decision to fly in the face of near universal scientific opinion doesn't come as a result of a lack of intellect, however, as experts who have studied vaccines and immunology acknowledge that many parents who don't vaccinate their children are well-educated.

    Which is asinine. There's many ways to be smart, and many entirely different ways to be educated. A degree in business administration or economics gives you no insight into not getting fooled by dumbass anti-vaxxers or various conspiracy theories. In fact, it may make it easier, since they're "educated" and don't think they can be fooled! It's just as easy to trick so-called "educated" people as it is non-educated people. The only difference is the bait you use.

    One of the reasons this anti-vaxxer stuff gets spread is we live in a world where we're taught that science is things printed in books, arguments that "sound right" rather than actually being educated on critical thinking skills, evidence based, and degrees of certainty.

  7. Educated but stupid by Anonymous Coward · · Score: 2, Insightful

    Higher educated, does not mean not stupid.

  8. Remember when it was just the Religous Right? by DalM · · Score: 3, Interesting

    Remember when it was just the religious right that was anti-science? Ah, those were the days. We could just mock them behind their backs and call then neanderthals. Ha ha. Oh, nostalgia.

    Turns out "religion" had nothing to do with it after all. A certain percentage of people will just believe whatever they want to believe, regardless of ethnicity, religion or economic status. Looking back, wasn't that always the case?

    1. Re:Remember when it was just the Religous Right? by DalM · · Score: 2

      Thank you. I wasn't sure I got my own point.

  9. bullshit by DogDude · · Score: 4, Insightful

    There's plenty of issues people have with vaccines that are based in science

    Like what, exactly?

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    1. Re:bullshit by smoot123 · · Score: 5, Insightful

      Adverse effects (usually around one in a million for most vaccines for severe adverse reactions, one in ten for most mild ones). Correlation here is risk calculation and game theory, not "stupid parents".

      First of all, remind yourself that wealthy parents in upper middle class tend to have only one child. That means that "all their eggs are in one basket".

      I think it's closer to two children but that doesn't really change your point. Both rug rats are precious snowflakes.

      What I think is missing is the alternative risk. Say there's a one in a million risk for a serous complication (I have no idea whether that's correct and what the complication might be. I do know autism isn't one of the possible complications.) What are the chances of getting measles without the vaccine? Apparently slightly higher than one in a million because we have more than 300 cases in Washington alone.

      Given that measles can kill you, I'm not sure it's all that clear cut that your snowflakes are safer without the shot.

    2. Re:bullshit by Luckyo · · Score: 2

      Autism, to my knowledge, is the "haha look at these dumb right wing nut job parents" that modern hysteria-chasing media is selling this as. These people do exist, but they appear to be a fairly small minority in this particular issue.

      The actual problem is mentioned in the OP - upper middle class, well educated and smart parents. Notably, you just failed the relevant risk assessment, because you failed to note the fact that as long as herd immunity holds, risk is effectively zero. You cannot contract a disease that doesn't exist within contagious range of you. It's only when the game theoretical scenario of "everyone around me is an altruist, therefore I should be an egoist" is figured out by sufficient amount of people in the same area that herd immunity begins to fail. So the conditions that appear to be needed to trigger this particular issue is a combination of understanding of risk assessment and game theory coupled with overestimation/underestimation of your neighbours.

      Places such as those that concentrate a lot of highly educated ideologically very far modern left likely fit because they have what appears to be significant self selected over-representation of outliers in terms of actual high intelligence, high mathematical and logical reasoning skill, and diminished social skills. Upper end of intelligence curve has a significantly elevated tendency to come with significant downsides when it comes to mathematical capabilities in terms of lack of social skills. That means that those are extremely intelligent people that have problems reading people. This profile would also match the recently risen problem with draconian thought control in many Silicon Valley giants. "We don't care about context, we just care about individual words" is literally the problem many of the people who are highly functional autists have in real life, because they have problems comprehending the social context of things being said and done by other people. That's literally what that condition is.

      And such people make brilliant workers for IT companies.

      As for serious complications for vaccinations, those are really nasty effects, that usually have a significant life long effect if you survive them. Autism is long debunked click bait distraction here. Real problems are things like severe immune system conditions. But they are genuinely one a million or so risk for most modern vaccines given to children. And yet, when you scale it to US for example, statistic projection suggests that there's around 400 people with those conditions who are alive and suffering or dead because of them. And that's just the extremely serious end. Less serious but still very damaging items on the "diverse effects" list are usually around 1/10.000 to 1/100.000. Former would mean around 40.000 people in US. That's no longer an insignificant number.

      Final factor in the risk assessment formula is the risk of actually suffering the nastier effects of those illnesses. In case of measles for example, death is about 1/10.000 with proper medical care. Contrast with diverse effects and you'll see where this argument is going.

      Which is likely why the modern programs aimed at "eliminating anti-vaccination movement" fail miserably. They're targeting the "anti-vaxxers" known in popular culture, the fairly uneducated families who tend to talk about conspiracy theories. They fail to target what appears to be intelligent upper middle class people who make the aforementioned risk assessment.

  10. Education is not equal to intelligence by grasshoppa · · Score: 4, Insightful

    I've met people who have plenty of fancy letters after their names, and they're dumb as rocks. They studied deep in a single field, but can only regurgitate knowledge, not integrate and extrapolate.

    The more life I experience, the more I realize just how truly rare intelligence is.

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  11. No by nospam007 · · Score: 2

    Just because you inherited money and your dad paid for a new library at Harvard doesn't mean that you aren't a stupid fuck.

  12. It's not that simple by DogDude · · Score: 2, Insightful

    Looking back, wasn't that always the case?

    No, I don't think it's that simple. Religion, by definition, is deliberate ignorance: believe something that has no basis in reality because it has no basis in reality. I don't know a whole heck of a lot of truly smart people who are also religious. I honestly don't know if I know any.

    But, religion is becoming passe. It's dying off quickly in more educated, modern societies (ie: Europe). Without religion, some people still have some sort of innate need to believe in something irrational, because the idea of "this is all there is" is just too much (or not enough?) for them. I think that these people who need something else, but who can't buy into the magical sky wizard thing are grasping at all sorts of things, and some of those things are online Internet conspiracies.

    Personally, I think that life as we know it is plenty interesting enough for me, so I don't understand why so many people need to look past that and believe in some sort of silly mumbo jumbo.

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    1. Re:It's not that simple by Cederic · · Score: 2

      I don't know a whole heck of a lot of truly smart people who are also religious.

      Several of the most intelligent (and best educated) people I know adhere strongly to their religious practices.

      Whether they actually believe any of that shit is something I'm very kind and don't press them on, but they're heavily into the 'must do' / 'must not do' shite purely on archaic superstitious grounds.

  13. social media responsible ? by swell · · Score: 5, Insightful

    Sorry to drag social media into the fray again, but it may have undue influence. The poorest, most ignorant people don't use social media much. When the doctor, or some authority, tells them to get vaccinations, they obey.

    But those steeped in social media see lots of opinions, lots of controversy, lots of fake news. When an authority tells them to get vaccinations, they think they know better.

    'All's fair in love and war', they say. Raising children is a very emotional activity. Parents tend to be protective and sometimes paranoid about obscure threats to their children. Rationality is sometimes overlooked when they find urgent online pleas to avoid vaxxing.

    I work with illiterate adults, helping them to be readers. They are very docile and will do what doctors tell them to do. The rest of us are too smart to fall for that blind obedience trap.

    --
    ...omphaloskepsis often...
  14. So it's settled by Opportunist · · Score: 4, Interesting

    It's not the dumb fucks but the selfish assholes. Gotcha.

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  15. Re:They are intelligent because they are liberal by meglon · · Score: 2

    ....and you're the definition of a partisan piece of shit. I don't give a fuck if they're conservative or liberal, anti-vaxxers are fucking idiots.... like you, only for a different reason. And no, they're not "almost all" liberals, only a stupid fucking idiot would say that when you have all these religious conservatives refusing to vaccinate their kids against HPV. But then, you are a partisan piece of shit.. so there's that.

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  16. Re: show butthoal by dgatwood · · Score: 4, Informative

    Do you get a smallpox vaccine? No, smallpox was eradicated.

    Unless you are working in labs that maintain samples of smallpox for research, this is probably true. That said, if a new outbreak ever occurs somehow (e.g. cross-species transmission), then being able to rapidly ramp up those immunizations could be pretty important.

    Do you get a chicken pox vaccine when you already had chicken pox? Probably not. The efficacy of having had chicken oox is better understood than the efficacy of the vaccine.

    Actually, that's untrue. People who have previously been infected by chickenpox need a vaccine booster later in life. The chickenpox virus is never completely eliminated from the human body, and as a result, it can resurface in the form of shingles, a painful and debilitating condition that affects a million people per year in the United States alone. Given that the chickenpox vaccine was not approved for use in the U.S. until 1995, exactly zero percent of the main at-risk age group (elderly) were vaccinated as a kid, which is to say that (approximately) all cases of shingles occur in people who had chickenpox, not the vaccine. But periodic booster vaccination can prevent it from occurring/recurring.

    Do you get your second dose of gardasil as a child? No, you get it later in life assuming you even want it or some guideline has not changed.

    Huh? Like all vaccines, protection lasts for a period of time.

    I would ask that you idiots please stop talking about vaccines as though they were some monolithic thing that everybody gets from big brother.

    Vaccines aren't all the same, but they are pretty darn similar except for the virus itself. They confer an immunity to a particular virus and similar viruses for a period of time. They must periodically be supplemented by a booster if continued immunity is required, and mutation of viruses can result in less or no protection (e.g. influenza). The only questions you need to ask are:

    • Am I at any real risk of exposure to that virus?

    That's it. There's really only a single factor to consider when deciding whether to be vaccinated. People who go to countries that have more viruses need more immunizations. People in the U.S. need fewer (but still more than none). And when groups of people refuse to get immunized, the herd immunity of the society they live in is reduced, and everyone is at greater risk of dying from what would otherwise be an entirely preventable disease.

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