RFK Jr. and vaccine politics

Several years ago, during the first Trump administration, I excoriated the then-nominee for Secretary of Health and Human Services, orthopedic surgeon Tom Price, for his poor understanding of cancer screening. (Secretary Price was confirmed by the Senate, but ended up serving for less than 8 months and resigning abruptly after Politico discovered he had spent $1 million in taxpayer dollars flying on private jets and military aircraft.) President-elect Trump has stated that he plans to nominate Robert F. Kennedy, Jr. for Secretary of HHS this time around. I don't know RFK Jr.'s views on cancer screening. News stories have focused on his beliefs about water fluoridation, unpasteurized ("raw") milk, and vaccine safety.

Few HHS Secretaries have actually been medical doctors; Dr. Price was the first M.D. to hold the position in 24 years. The position has typically been filled by former Congresspeople, governors, and professional administrators. The majority of the department's budget funds the Medicare and Medicaid health insurance programs. Smaller portions are distributed to researchers through competitive grant applications. RFK Jr. may want to take fluoride out of the water, ramp up consumption of raw milk, and make vaccines optional for school entry, but fortunately, HHS doesn't have direct jurisdiction over any of these issues. State and local governments decide what vaccines to require. As illustrated in a recent Health Affairs analysis, routine vaccine recommendations from the Centers for Disease Control and Prevention (CDC)'s Advisory Committee on Immunization Practices (ACIP) take anywhere from 9 months to 15 years to be incorporated into state requirements for school entry, and in a few cases (such as human papillomavirus vaccine), have yet to be incorporated at all.

I've written previously about the marked contrast between HPV vaccine's extraordinary effectiveness and its underutilization in the U.S., and it strikes me as nonsensical that parents who don't bat an eye at their infants being vaccinated against hepatitis B (a sexually transmitted infection that causes cirrhosis and liver cancer) are reluctant to protect these children a decade later against a sexually transmitted infection that causes cancer. As vaccine law expert Richard Hughes pointed out in a recent essay, however, vaccine politics frequently defies public health interests. As a member of the Arkansas State Board of Health, he unsuccessfully lobbied for an HPV vaccine requirement:

I approached Governor [Mike] Huckabee’s health adviser and mentioned my interest in promoting the policy’s adoption through the board. The governor’s endorsement, I urged, would demonstrate his commitment to public health as he prepared to make a bid for the presidency. The response was a predictable but polite “no.” For all his championing of public health, the governor was a conservative former Baptist pastor. Many of his strongest supporters would undoubtedly object to the vaccine mandate on moral grounds. Moreover, it could cost him support in the 2008 presidential primaries, where he eventually came in second place to John McCain.

In another important paper, University of Pennsylvania professor Angela Shen warned of "three significant forces in play that jeopardize the continued success of vaccines": the withdrawal of federal support for COVID-19 and other vaccines for uninsured adults; a rising tide of misinformation and disinformation; and a "growing political and partisan divide" around vaccines. During the pandemic, RFK Jr. was identified by researchers as one of the "Disinformation Dozen" - 12 people who originated or amplified 65% of misleading or erroneous anti-vaccine claims on social media platforms. In 2019, his anti-vaccine platform was powerful enough to convince a large portion of the population of Samoa to refuse measles, mumps, and rubella (MMR) vaccines after two children died after receiving MMR vaccines that were accidentally mixed with expired anesthetic rather than the appropriate diluent. As a result, the following year a measles outbreak caused 5,700 cases (3% of the population) and 83 deaths.

A CDC report published yesterday showed that uptake of influenza, COVID-19, and respiratory syncytial virus (RSV) vaccine among adults has been modest as we enter the respiratory virus season (previously known as "flu season"). 35% and 18% of adults have received this year's flu and COVID-19 vaccines, respectively, and 30-40% of eligible adults (age >75 or age 60-74 at increased risk for severe disease) have ever received an RSV vaccine (including last year). COVID-19 vaccine uptake is actually a bit higher than last year, though with less than half of seniors having received it, there are still a lot of vulnerable adults out there.

Side note: Kristen Panthagani, writing in Your Local Epidemiologst, had a fantastic post in September explaining the multiple mistakes in health communication that (mis)led many Americans to expect a "perfect" COVID vaccine. The bottom line: no vaccine confers 100% immunity or is 100% protective for life. The reason we rarely see measles or polio or diphtheria anymore is that 95% or more Americans have been vaccinated and have some immunity, so a chain of transmission has trouble getting established. But if and when that percentage drops, watch out! (See Samoa, 2019.)

It shouldn't surprise any of you that I strongly oppose having RFK Jr. become the next Secretary of HHS. It isn't because he isn't a health professional or doesn't have any experience running an organization of this size (or even the smaller size it might become once the inefficiently two-headed Department of Government Efficiency goes after it). It isn't even because he's a longtime antivaxxer. It's because RFK Jr. has shown time and time again that no amount of scientific evidence will change his deeply rooted, crackpot conspiracy theories about public health. Regardless of the actual influence he might wield in this position, America doesn't need RFK Jr. "going wild on health" when going wild means more cavities for kids, more foodborne illnesses, and more suffering from vaccine-preventable diseases.

Cholesterol screening in children

The appropriateness of screening for hyperlipidemia in children has been debated for years in the medical literature, including the pages of American Family Physician. In 2010, Dr. Robert Gauer wrote an editorial arguing that screening could identify children at risk of developing premature atherosclerotic cardiovascular disease (ASCVD) and allow clinicians to counsel these patients about lifestyle modification and to start statin therapy.

On the other hand, an opposing editorial by former U.S. Preventive Services Task Force (USPSTF) Chair Michael LeFevre noted that “only 40 to 55 percent of children with elevated cholesterol and low-density lipoprotein (LDL) levels will continue to have elevated lipids on follow-up,” reviewed limitations in the evidence base for screening and treatment, and cautioned physicians against “caus[ing] unintended negative consequences in our zeal to prevent far-off disease.”

In 2012, an AFP Journal Club piece analyzed an article contrasting the USPSTF’s call for more research on childhood lipid screening to an American Academy of Pediatrics (AAP)-endorsed guideline, which suggested checking lipid levels in all children around age 10. Dr. Andrea Darby-Stewart and colleagues favored the USPSTF’s “more rigorous, albeit conservative” position over the AAP’s:

There is no evidence that early identification of hyperlipidemia in children changes long-term outcomes. Let’s focus our limited health care resources where they may do some good: encouraging physical activity and maintaining an appropriate body weight.

The 2019 article, Right Care for Children: Top Five Do’s and Don’ts by Dr. Matthew Schefft and colleagues, revisited the controversial topic and listed routine hyperlipidemia screening in children and adolescents as an overused intervention. In a Letter to the Editor, Drs. Cezary Wojcik and Samuel Gidding disagreed and offered another justification for universal lipid screening: to detect familial hypercholesterolemia, an asymptomatic genetic condition that affects 1 out of every 250 children and leads to premature coronary artery disease.

In the September 2024 issue of AFP, the USPSTF reaffirmed its previous statements that the evidence is insufficient to determine the balance of benefits and harms for screening for lipid disorders in asymptomatic persons 20 years or younger. A Putting Prevention into Practice case study applied the USPSTF’s statement to a common clinical scenario. Finally, an editorial by Dr. Brian Reamy proposed selectively screening for familial hypercholesterolemia with a lipid profile "for all family members older than 9 years who have a first-degree relative with a premature ASCVD event or a relative receiving treatment for LDL cholesterol greater than 190 mg per dL."

Currently, cholesterol screening in children is uncommon. A US electronic medical record study of more than 3.2 million children found that among 9 to 11 year olds, only 9% had a previous lipid profile, rising to 13% in the 17- to 21-year-old group. Although prospective cohort studies have found associations between childhood risk factors and adult cardiovascular events, the value of a lipid profile as a risk factor was called into question by a recent analysis of seven cohorts in the United States, Australia, and Finland (n = 11,500). A multivariable model derived from the data used age, sex, blood pressure, body mass index, and smoking status to predict adult cardiovascular events. Adding lipid measurements to the model did not improve risk prediction.

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This post first appeared on the AFP Community Blog.

Legalizing cannabis for medical and recreational use: unintended consequences

Four states voted in yesterday's election on ballot measures to legalize or regulate marijuana (cannabis). As of this morning, it appears that Nebraska will legalize medical cannabis, while Florida, North Dakota, and South Dakota rejected legalizing cannabis for recreational use. A recent study described trends in medical cannabis licensure in 38 states and Washington, DC, from 2020 to 2022. The overall number of enrolled patients increased from 3.1 to 4.1 million, but 13 of the 15 jurisdictions that have legalized recreational use saw decreased enrollment, likely because patients no longer needed a clinician’s authorization to legally purchase cannabis. (In my state of Pennsylvania, where recreational use remains illegal, the prevalence of patients using medical cannabis more than doubled from 236 to 549 per 10,000 people.) Of concern, the percentage of patient-reported qualifying conditions with “substantial or conclusive” evidence supporting benefits of cannabis, as according to the National Academies of Sciences, Engineering, and Medicine, declined from 70% to 54%.

A 2022 Agency for Healthcare Research and Quality review and American Family Physician commentary by Drs. Dean Seehusen and Kaitlin Kehoe concluded that cannabis produced “small to moderate short-term pain relief” in patients with neuropathic pain. Similarly, a review of cannabis and pain management in the current issue of the Journal of the American Board of Family Medicine found low- and moderate-quality evidence that cannabis relieves neuropathic pain or rheumatoid arthritis, fibromyalgia, and other chronic noncancer-related pain. Adverse effects are common, with the most serious and prolonged being cannabinoid hyperemesis syndrome. A previous AFP article presented a suggested approach to distinguishing high-risk use and cannabis use disorder from potentially appropriate medical uses.

In New York, where recreational cannabis became legal in 2021, a New York Times Magazine story examined the problems associated with regulating sales of a substance that, similar to tobacco and alcohol, is highly addictive. Unlicensed shops dispensing cannabis vastly outnumber legal dispensaries because the former’s products can be priced more cheaply and thus cater to customers with cannabis use disorder:

Perhaps marijuana is not as bad as alcohol or cigarettes. But saying it is not as bad misses the point: Marijuana does hurt a substantial portion of its consumers, often quite badly. And there is no reason to think that businesses won’t sell marijuana to those it hurts, if they’re allowed to. What the alcohol and tobacco markets show us, rather, is that addiction and profit don’t mix well. … The goal is to find a balance between the harms of prohibition and those of commercialization.

Although many adults in the United State believe that cannabis use and secondhand smoke exposure is safer than that from tobacco, there is ample evidence of negative effects on short- and long-term outcomes. An FPIN Clinical Inquiry found that legalization of recreational cannabis is associated with an increase in cannabis-related emergency department visits. A recent systematic review and meta-analysis of 63 observational studies (n = 438,329) concluded that cannabis use in those younger than 24 years is associated with lower school grades; lower likelihood of high school graduation, university enrollment, and postsecondary degree attainment; and increased school dropout rates and absenteeism.

Finally, a cross-sectional analysis of data from the 2021-2022 National Survey on Drug Use and Health found that 16% of full-time employed adults used cannabis in the previous month, with 6.5% meeting criteria for cannabis use disorder. A dose-response relationship occurred between increasing frequency of cannabis use and cannabis use disorder severity and increased incidence of missed work for illness, injury, or nonmedical reasons.

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This post first appeared on the AFP Community Blog.