Saturday, November 19, 2016

Conflicts of interest at the CDC?

Lundy Bancroft writes:

As many of you who watch the news may already be aware, there is an overly close relationship between the Centers for Disease Control (CDC) and the pharmaceutical companies. I don’t think the CDC, or its related group the Institute of Medicine, can be considered objective when there is such a great amount of funding coming to the CDC from vaccine manufacturers, and so much personnel going back and forth between serving in CDC positions and working in drug industry positions.

Overall I agree with Lundy on this point. To ensure the public's trust, the CDC needs to maintain clear boundaries between itself and the private sector, with a couple caveats.

  • Caveat one: the CDC is an agency with a 11.5 billion dollar annual budget that comes from taxpayers. The CDC does not directly receive funding from the pharmaceutical industry; rather, that funding goes into the CDC Foundation, which took in 145 million dollars in 2015, or just over 1% of the CDC budget. The concept of the "CDC Foundation" seems intrinsically rather dubious, regardless of the good work it may perform. However, measured in dollars, the CDC Foundation remains a small fraction of CDC-associated operations.
  • Caveat two: it isn't realistic or desirable to demand total objectivity (and a total lack of private sector experience) from those who work at the CDC. People who work in public health tend to support vaccination efforts and other interventions, and want to see their work make an impact. Working in the pharmaceutical industry is a valid and important path to that goal. It shouldn't prevent qualified individuals from transitioning to work for the CDC.

Given that no individual can be completely objective, it's important for public agencies to have strong conflict of interest policies (and to follow them). Unfortunately, the CDC has historically come up short in this regard. Below I will focus on the CDC's Advisory Committee on Immunization Practices (ACIP) and the FDA's Vaccines and Related Biological Products Advisory Committee (VRBPAC), which are the top-tier committees that respectively recommend (CDC) and license (FDA) vaccines in the United States.

In 2000, the Committee on Government Reform of the US House of Representatives released a report detailing the excessive use of conflict-of-interest waivers within ACIP and VRBPAC. The report is available here. (Note: I do not personally endorse the positions of the National Vaccine Information Center.) Between 1995 and 2000, there were multiple documented instances of individuals with industry affiliations and/or financial interests being allowed to attend ACIP or VRBPAC meetings and even vote on vaccine recommendations related to their outside interests. It is not clear if anything has changed since 2000, although the official meetings of these committees are a matter of public record.

In light of this (somewhat old) information, what can interested parties do? One starting point is to look at ACIP meeting minutes and personally review the discussions that lead to vaccine recommendations. Without a doubt, there may be many off-the-record conversations that surround these meetings. However, the minutes at least provide a way to inspect the integrity of the final discussions that lead to influential vaccine recommendations.

As a footnote, here are some instances where the CDC's recommendations have been directly or indirectly questioned in academic journals. (Note: I do not condone all of the opinions expressed in these editorials. For example, I'm strongly in favor of HCV screening but I will save that for a future post.) Please be aware that some or all of the issues described in these editorials have not been definitively settled.

Editorial questioning the CDC
Editorial on approval of HPV vaccines
Study on conflicts of interest for HPV vaccines
Editorial on Lyme vaccines
Editorial on Rotavirus vaccines
Editorial on HCV screening

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