Sunday, January 18, 2015

We Went to Disneyland and All We Got Were These Stupid Measles.

No, not my family.  Unfortunately, that's what several families have to say now about their recent trip to the Happiest Place on Earth.

I've watched the emergence of anti-vaccination sentiment over the past few years with a mixture of fascination and horror.  While in med school and residency, the idea of people willingly turning their nose up at vaccination never crossed my mind.  I mean, vaccines!  No brainer!  The biggest success story of modern medicine!  Eradication of smallpox!  Polio eliminated from the developed nations of the world!  How in the world could anyone be opposed to such a thing?

Then, in 1998, Andrew Wakefield published a small case study in the Lancet that hypothesized a link between the MMR vaccine (the combination vaccine for measles, mumps and rubella) and autism.  At first, this didn't get too much press in the US.  However, in England it became a Big Deal.  Even though his paper did not explicitly state that the MMR caused autism, Wakefield held a press conference before the article was even published calling for suspension of the use of the MMR vaccine.  This led to a rather spectacular fall in MMR vaccination rates in the UK over the next decade.

Then, in 2005, the proverbial you-know-what hit the fan in the US.  Robert F. Kennedy Jr. wrote an article called "Deadly Immunity" which was published in Rolling Stone Magazine.  This article claimed that there were excessive amounts of thimerosal, a mercury-based preservative, in childhood vaccinations, basically leading to mercury poisoning and causing autism.  You can still read the full article on RFK Jr's site.  You're not going to find it anymore on Rolling Stone or Both magazines retracted the article and wiped it from their sites after it was shown to be riddled with inaccuracies and downright falsehoods.

Now, interestingly, the MMR vaccine has never contained thimerosal.  In addition to this, out of an abundance of caution, thimerosal was removed from US childhood vaccines in 1999.  Today, in 2014, autism rates continue to rise.  It's not thimerosal causing it.

It's also not the MMR.  The studies have been done, and the science is in.  As if that wasn't enough, The Lancet retracted Wakefield's paper after overwhelming evidence showed that he was paid by plaintiff's lawyers to find a link between the MMR and autism.  In addition to this, Wakefield himself was trying to develop a alternative vaccine that would be "safer."  He performed unethical, invasive tests on children, leading to potentially deadly complications in one of them.  Other scientists were unable to replicate his original findings.  In 2010, the British General Medical Council pulled his license to practice medicine.

You'd think this would be enough to put the fears about the MMR to rest.

It's not.  Not even close.

I followed these issues only very peripherally until 2007, when I gave birth to my first child.  That's when I fell down the true rabbit hole.  Like any new parent, I wanted to do my best for my little one.  And, like any new parent, I turned to the internet to lead me to what, exactly, "the best" was.  That's when my eyes were opened to a whole world of woo.  I was stunned to find that there were entire forums dedicated to not vaccinating, among other things.  Forums where if you dared to correct someone or even share a dissenting opinion, you were shouted down, accused of being paid by Big Pharma, or just flat-out banned.  And it wasn't just autism that vaccines were supposed to cause.  They also caused SIDS, autoimmune disease, encephalopathy, allergies...the list goes on and on.  How were they causing all of this?  Well, sometime it was the thimerosal.  Sometimes it was the MMR.  Sometimes it was "too many too soon."  Sometimes it was aluminum.  The goalposts were constantly moving.

These issues are complex and I could probably write forever on it.  However, other bloggers have been at this for much longer than me.  I suggest starting with Respectful Insolence, which is written by a cancer surgeon who has been at this for more than a decade.  Science-Based Medicine is also an excellent site.  The Panic Virus, by Seth Mnookian is an excellent book and a quick, fascinating read.

The upshot of the entire vaccination controversy is that rates of vaccination are falling.  They are the lowest in areas where parents are the wealthiest and best educated.  This may seem counter-intuitive at first, but it really makes perfect sense.  It's the Dunning-Kruger effect in action.  A minimal amount of knowledge leads to an immense overestimation of expertise.  Therefore, educated people truly believe that they can research some things on Google and gain the same level of expertise as scientists who have been studying this stuff for years.  These are also a group of people who are used to nothing but success in life.  They labor under the assertion that being able to afford the best in organic food, healthy lifestyle and alternative medicine will protect them from infectious disease.

Anyway, refusing vaccines is leading to the inevitable outcome- we are starting to see the resurgence of once-eliminated diseases.  During Christmas week, someone visited Disneyland in California who was becoming ill with the measles.  Measles is one of the most communicable viruses known- up to 90% of people exposed will become infected if they are not already immune.  The vaccine is highly effective- between 95-98% effective.  Just check out this graph.

But it only works when you use it.  And when immunization drops below a certain threshold, outbreaks will occur, which is exactly what happened at Disney.  The outbreak seems to have been traced to an unvaccinated woman in her 20's.  From this one index case, there are now 51 active cases in four states.  The exposures continue- a clinic in San Diego had to be shut down after six siblings visited with measles.  Since the measles virus is airborne, the virus can linger in the air for hours after an infected person had been in the vicinity.

As quickly as things seem to be spreading, this story is also a testament to the effectiveness of the measles vaccine.  During Christmas week at Disneyland, there are an estimated 80,000 visitors a day. Even estimating that only 80% of those visitors were vaccinated, that is 64,000 potential exposures. It's hard to find out exact numbers of how many of the 31 directly infected at Disney were vaccinated, although reports state that "most" were unvaccinated.  However, let's say, for argument's sake, that they were all vaccinated.  That still represents  an incredible effectiveness rate of greater than 99%.

Despite what many anti-vaccine websites will have you believe, measles is not benign. In developed countries, the mortality rate is 3/1000.  Other complications include pneumonia, ear infections, deafness, and SSPE, which is fatal. I have no doubt that if vaccination rates continue to drop, we will start to see some of these complications occurring.  Just look at what happened in France:
Although few measles cases were reported in France during 2006 and 2007, suggesting the country might have been close to eliminating the disease, a dramatic outbreak of >20,000 cases occurred during 2008–2011. Adolescents and young adults accounted for more than half of cases; median patient age increased from 12 to 16 years during the outbreak. The highest incidence rate was observed in children <1 year of age, reaching 135 cases/100,000 infants during the last epidemic wave. Almost 5,000 patients were hospitalized, including 1,023 for severe pneumonia and 27 for encephalitis/myelitis; 10 patients died. More than 80% of the cases during this period occurred in unvaccinated persons, reflecting heterogeneous vaccination coverage, where pockets of susceptible persons still remain. Although vaccine coverage among children improved, convincing susceptible young adults to get vaccinated remains a critical issue if the target to eliminate the disease by 2015 is to be met.
Scary.  Not the future I want to envision here.

One more issue.  Another story made the news- a young woman, unvaccinated by choice, was refusing to be quarantined after being exposed to her sister while she was infectious with measles contracted at Disneyland. The selfishness exhibited by her is breathtaking.  She doesn't think it's fair that she should be quarantined when she's not even sick.  Her mom think's it's "not nice" that her daughter is being "threatened."  Well, I think it's "not nice" that someone who is potentially infectious sees nothing wrong with wandering about the community, infecting those too young to get vaccinated or who are immunocompromised by illness or chemotherapy.

Here's my take: if you want to practice 19th century medicine and turn your nose up at vaccination, be prepared to suffer the 19th century consequence- quarantine.

Get your vaccines, people.  Make sure your boosters are up to date.  Vaccinate your children.  Remember, the good old days often weren't that good.  Let's move forward, not backwards.