- given you are exposed to tetanus and unvaccinated, you will experience uncomfortable/painful symptoms even if you don’t die
- a vaccinated person when exposed to tetanus will not experience symptoms
- given they don’t experience symptoms, the medical system will have no knowledge of this, so those cases are underreported
your argument seems to hinge on the cost of a bad day from vaccination outweighing statistical seconds of lifespan, but doesn’t take into account benefit of preventing symptoms even if you don’t die
presumably you agree there is a mechanism by which tetanus can harm you and that there is a mechanism by which the vaccine prevents that harm. if you’re taking the outside view and looking at some stats, then i think the stats would likely not adequately capture the harms
I was about to make this point too: Bryan is comparing the (low) risk of death to the unpleasantness of the shot. Why not factor in the unpleasantness of getting a non-lethal case of tetanus? That said, it's likely you still made the correct call. But let's not settle for anything less than full numeracy.
hm actually maybe issue with my reading comprehension. your gripe is specifically with the booster. and apparently someone fully vaccinated for tetanus as a child doesn’t need a booster.
i guess my question for you would be do you think those that weren’t “fully vaccinated as children” need the booster? or do you think even in that case they should reject it?
Yeah for us old guys we've noticed the CDC and WHO are fighting a really slow, and successful, fight to get rid of tetanus boosters. It used to be in the 60s "every time you were deep cut" (got 3 boosters in a single year when I was a rural kid) and then every five years and now every ten. I think this is a rare case where the CDC actually agrees and knows the booster is pointless and has for a long time, but also understand change is generational so is pushing it out at a glacial pace to avoid politics. And it's being successful as it really has no affect on doctors income whereas mammograms, dental X-rays/cleanings, etc all have cottage industries around them.
Yes, as a recently retired doc, my understanding in recent years was that the booster was pointless in those previously vaccinated, with tetanus (rare as it is) effectively never occurring in people who were vaccinated at some point in their life, no matter how long ago.
However, the recommendations were lagging. As you say, it went from “when you have an open wound, give a tetanus booster unless absolutely sure you had one in the last five years (which meant pretty well everyone got one every time, because nobody seemed to remember when their last shot was given)” to “give every five years” to “give every ten years”.
With the rise of guidelines-driven medicine, tetanus vaccine got onto the checklists of things that were often forgotten but possibly should be done, so it became routine to ask about, recommend, and give the vaccine, in order to check a box on a form. I know that in Nova Scotia, where I worked, they introduced a “chronic disease management” incentive fee, applicable to diabetes, etc., and one of the criteria was “vaccines up to date”. At that point, not only were you paid for giving the shot, but you also got an incentive for the chronic disease management (assuming you met the other targets as well).
So, combination of medical practice not keeping up with best evidence, guidelines creating tick boxes and the imperative to do unnecessary things, and financial incentives that don’t make sense.
Yeah it’s an extremely uncomfortable disease, to put it mildly. You also have to factor in the morbidity acquired from being on a ventilator for 6 weeks. Not saying that’s enough to change the decision, but only putting potential death in the negative columns misses the broad spectrum of bad outcomes. This is what makes disease risk difficult to quantify.
> given you are exposed to tetanus and unvaccinated, you will experience uncomfortable/painful symptoms even if you don’t die
This shows the same problem as the community note - it isn't true that the lack of American deaths from tetanus is primarily due to widespread vaccination.
It's primarily due to a lack of exposure to tetanus. As was already noted, tetanus isn't contagious. You have to be doing something weird, like running around barefoot in an area full of metal debris, to get it. (The paradigm case for catching tetanus is someone who steps on a rusty nail; the nail or other metal will have to break the skin.)
The tetanus vaccine isn't like the practice of cooking your food before you eat it, where the world is constantly assaulting you with serious dangers and you need a barrier to hold them off. It's like the practice of filming sharks from within a steel cage. The cage is a good idea, if you're committed to being near sharks, but the threat doesn't exist unless you want it to. My no-cage approach to shark safety is a lot safer than a filming crew's yes-cage approach, with the bonus of a much lower risk of suffocation.
i have no numbers, so it’s just anecdote vs anecdote, but the analogy to shark/cage feels disingenuous. i have never seen a shark in person in my life. i have been inches away from ostensibly rusty metal countless times. on multiple occasions i have cut or punctured my skin with ostensibly rusty metal. i am not some person that works with metal all the time. there is just a lot of metal everywhere and it’s not uncommon for it to rust.
in any case i understand that the outside view is trying to do some very rational analysis on the incidence of tetanus vs the exposure rate vs whatever, but i’m just not sure that’s the approach we should use. it feels blasphemous to say that, but if i put my midwit hat on then it seems ok. i’m surrounded by metal. some of it is rusty. i’ve even punctured my skin with metal. wounds from rusty metal can cause tetanus. tetanus is unpleasant
with that said, i think none of the above is relevant. bryan caplan is making a more nuanced point very specifically about the tetanus booster (not the tetanus vaccine in general). i don’t think i disagree. when i google if the booster is required many sources say no. so now i don’t understand why anyone cares about this topic.
my understanding at this point is that bryan’s doctor suggested the booster when it’s likely this isn’t necessary, bryan tweeted something that is very easy to misinterpet, the internet misinterpreted it, and bryan misinterpreted the internet’s reaction
i’m a little confused here. my understanding is:
- tetanus can be treated even if unvaccinated
- given you are exposed to tetanus and unvaccinated, you will experience uncomfortable/painful symptoms even if you don’t die
- a vaccinated person when exposed to tetanus will not experience symptoms
- given they don’t experience symptoms, the medical system will have no knowledge of this, so those cases are underreported
your argument seems to hinge on the cost of a bad day from vaccination outweighing statistical seconds of lifespan, but doesn’t take into account benefit of preventing symptoms even if you don’t die
presumably you agree there is a mechanism by which tetanus can harm you and that there is a mechanism by which the vaccine prevents that harm. if you’re taking the outside view and looking at some stats, then i think the stats would likely not adequately capture the harms
I was about to make this point too: Bryan is comparing the (low) risk of death to the unpleasantness of the shot. Why not factor in the unpleasantness of getting a non-lethal case of tetanus? That said, it's likely you still made the correct call. But let's not settle for anything less than full numeracy.
hm actually maybe issue with my reading comprehension. your gripe is specifically with the booster. and apparently someone fully vaccinated for tetanus as a child doesn’t need a booster.
http://news.ohsu.edu/2020/02/25/adults-dont-need-tetanus-diphtheria-boosters-if-fully-vaccinated-as-children-study-finds
i guess my question for you would be do you think those that weren’t “fully vaccinated as children” need the booster? or do you think even in that case they should reject it?
Yeah for us old guys we've noticed the CDC and WHO are fighting a really slow, and successful, fight to get rid of tetanus boosters. It used to be in the 60s "every time you were deep cut" (got 3 boosters in a single year when I was a rural kid) and then every five years and now every ten. I think this is a rare case where the CDC actually agrees and knows the booster is pointless and has for a long time, but also understand change is generational so is pushing it out at a glacial pace to avoid politics. And it's being successful as it really has no affect on doctors income whereas mammograms, dental X-rays/cleanings, etc all have cottage industries around them.
Yes, as a recently retired doc, my understanding in recent years was that the booster was pointless in those previously vaccinated, with tetanus (rare as it is) effectively never occurring in people who were vaccinated at some point in their life, no matter how long ago.
However, the recommendations were lagging. As you say, it went from “when you have an open wound, give a tetanus booster unless absolutely sure you had one in the last five years (which meant pretty well everyone got one every time, because nobody seemed to remember when their last shot was given)” to “give every five years” to “give every ten years”.
With the rise of guidelines-driven medicine, tetanus vaccine got onto the checklists of things that were often forgotten but possibly should be done, so it became routine to ask about, recommend, and give the vaccine, in order to check a box on a form. I know that in Nova Scotia, where I worked, they introduced a “chronic disease management” incentive fee, applicable to diabetes, etc., and one of the criteria was “vaccines up to date”. At that point, not only were you paid for giving the shot, but you also got an incentive for the chronic disease management (assuming you met the other targets as well).
So, combination of medical practice not keeping up with best evidence, guidelines creating tick boxes and the imperative to do unnecessary things, and financial incentives that don’t make sense.
Yeah it’s an extremely uncomfortable disease, to put it mildly. You also have to factor in the morbidity acquired from being on a ventilator for 6 weeks. Not saying that’s enough to change the decision, but only putting potential death in the negative columns misses the broad spectrum of bad outcomes. This is what makes disease risk difficult to quantify.
> given you are exposed to tetanus and unvaccinated, you will experience uncomfortable/painful symptoms even if you don’t die
This shows the same problem as the community note - it isn't true that the lack of American deaths from tetanus is primarily due to widespread vaccination.
It's primarily due to a lack of exposure to tetanus. As was already noted, tetanus isn't contagious. You have to be doing something weird, like running around barefoot in an area full of metal debris, to get it. (The paradigm case for catching tetanus is someone who steps on a rusty nail; the nail or other metal will have to break the skin.)
The tetanus vaccine isn't like the practice of cooking your food before you eat it, where the world is constantly assaulting you with serious dangers and you need a barrier to hold them off. It's like the practice of filming sharks from within a steel cage. The cage is a good idea, if you're committed to being near sharks, but the threat doesn't exist unless you want it to. My no-cage approach to shark safety is a lot safer than a filming crew's yes-cage approach, with the bonus of a much lower risk of suffocation.
i have no numbers, so it’s just anecdote vs anecdote, but the analogy to shark/cage feels disingenuous. i have never seen a shark in person in my life. i have been inches away from ostensibly rusty metal countless times. on multiple occasions i have cut or punctured my skin with ostensibly rusty metal. i am not some person that works with metal all the time. there is just a lot of metal everywhere and it’s not uncommon for it to rust.
in any case i understand that the outside view is trying to do some very rational analysis on the incidence of tetanus vs the exposure rate vs whatever, but i’m just not sure that’s the approach we should use. it feels blasphemous to say that, but if i put my midwit hat on then it seems ok. i’m surrounded by metal. some of it is rusty. i’ve even punctured my skin with metal. wounds from rusty metal can cause tetanus. tetanus is unpleasant
with that said, i think none of the above is relevant. bryan caplan is making a more nuanced point very specifically about the tetanus booster (not the tetanus vaccine in general). i don’t think i disagree. when i google if the booster is required many sources say no. so now i don’t understand why anyone cares about this topic.
my understanding at this point is that bryan’s doctor suggested the booster when it’s likely this isn’t necessary, bryan tweeted something that is very easy to misinterpet, the internet misinterpreted it, and bryan misinterpreted the internet’s reaction