The past few weeks have seen big news for vaccines. A bill related to vaccine exemptions was signed into law, a court ruled against a parent’s refusal to vaccinate and a recent study points out the value of vaccinating a household — especially mom — to protect a young infant from pertussis (whooping cough).
The latest news is that Governor Jerry Brown in California signed a bill last Sunday that had been sitting on his desk since September 6 and was the target of a number of rallies by parents who didn’t want to see it pass. Among those fighting the bill was Dr. Bob Sears, who says he walks a middle ground with vaccine policy but in reality tends to flirt with those who fear vaccines and rely on misinformation. Although some parents claimed the bill took away their right to choose whether their children get vaccinated, it actually just ensures they get good medical information before they make that choice.
Photo by Dave Gostisha at sxc.hu.
The bill-now-law, AB 2109, proposed by a pediatrician, requires parents to get a statement signed by a health care practitioner that the parents/guardians have received accurate, evidence-based information about the risks and benefits of vaccines before they can use a personal belief exemption to prevent their children from being vaccinated. This law is a tremendous triumph both for informed consent in medical decisions and for the public health of children in California, which saw a considerable outbreak of pertussis (whooping cough) in 2010. Washington state passed a similar law last year and saw 25 percent drop in exemptions filed. Other states are considering similar laws in a nationwide overall shift toward strengthening exemption requirements.
Why are these laws so important? In short, they kill two birds with one stone: They make it more difficult for parents to casually opt out of vaccines on philosophical grounds (as opposed to religious or medical reasons), and they require parents who want to opt out to at least hear out a pediatrician on accurate information about the actual risks (which do exist) and benefits (there are so many) of immunizations. Parents who are determined not to vaccinate their children can still refuse, but many parents who might have signed those forms out of convenience — it can be easier to sign than to get to the doctor’s office for the shot — will now at least hear the impact a decision not to vaccinate can have on the community. (Hopefully, they go to a health care practitioner other than Dr. Sears, whose stances have gradually been moving further and further toward unscientific and misinformation of those who oppose vaccines.)
It’s also particularly notable that California and Washington are the most recent states to tighten opt-out procedures for parents because they are home to some of the more recent pertussis outbreaks. More on that in a moment.
First, a bit of background on vaccine exemptions: Only 20 states have personal belief exemptions, and until last year, eight of these simply require nothing more than a parent signature. Now that number is down to six. (Other types of requirements for philosophical exemptions include writing out your reasons for exemption, requiring the forms to be notarized, requiring education on the risks/benefits, direct involvement from the state or local health department or renewals.)
All states have medical exemptions for patients who have auto-immune disorders, have proof that their bodies do not respond to immunization, have documented allergic reactions or have other circumstances which make it too risky for them to be immunized. In fact, these are the very people that the rest of the population protects through herd immunity when vaccination rates are up where they should be. All but two states have religious exemptions (Mississippi and West Virginia are the exceptions).
And that brings us to some less covered but still significant news about one state’s ruling on a particular case involving religious exemption. Last week, the U.S. district court in Ohio ruled that one woman’s claim of religious objection was insufficient for her children to be exempted from being vaccinated. Read the whole story here. To be fair, this is a complex case involving far more than vaccines; the mother is clearly neglectful and the overall situation is pretty crappy. However, the fact that the court found “the mere assertion of a religious belief … does not automatically trigger First Amendment protections,” and that “it has long been recognized that local authorities may constitutionally mandate vaccinations” is significant in a state that offers both religious and personal belief exemptions.
The constitutionality of religious exemptions is dubious as well. At the very least, however, anyone seeking any exemption should certainly to see a doctor first to be sure they have accurate information and not simply what they have seen online or heard at the playground. Those who absolutely will not vaccinate in states without exemptions may also opt to home school or send their children to private schools that don’t have requirements. But considering the increasing rates of measles and the increasing epidemics of pertussis, the need for high vaccination coverage in communities is more important than ever.
It is true that the pertussis vaccine is not as effective as the old one used to be, something I wrote about a few weeks ago. It’s also true that pertussis peaks every five years or so, but even taking into account the peaks, the overall rate of cases has been steadily on the move upward. Dr. Offit, the chief of the Division of Infectious Disease at Children’s Hospital of Philadelphia and a very vocal advocate of vaccines, said he believes that parents’ refusals to vaccinate are playing their own small part in the increase.
“The major contributor is waning immunity. The minor contributor is the choice not vaccinate,” he said. He noted that there are researchers working on the problem, as this Nature article notes (paywall), including attempts to make a better vaccine with more adjuvants, the additives that enhance the body’s immune response to a vaccine. While vaccinated children and adults have been high among the numbers of those getting whooping cough, getting the vaccine remains among the best ways to reduce your risk of contracting it — or of having less rough of a time with it if you do get it. Dr. Offit also pointed out that pregnant women in particular should be sure they get their booster.
Which brings us to the study published last week that relates to the most important reason to get vaccinated, at least from the perspective of preventing deaths — to protect the babies who are too young for the vaccine but most likely to contract it and die from it.
The study, published in the journal Epidemiology last week, looked at how frequently pertussis was transmitted to others within the same household and how effective “cocooning” is. Cocooning is vaccinating all the household members who can get the vaccine for the purpose of protecting young babies who can’t yet be vaccinated for the disease.
They found that transmission rates within the home are high, especially for mothers passing the illness on to their children. Therefore, making sure all pregnant women are vaccinated before their baby arrives would, according to their calculations, cut the risk in half that a baby would contract pertussis. The evidence for sibling vaccination, though weaker, still points to the value of overall cocooning: “Vaccination of siblings is less effective in preventing transmission within the household, but may be as effective overall because siblings more often introduce an infection in the household.”
Indeed, this year, siblings’ bringing home the disease appears more likely than ever in the states experiencing big outbreaks this year. Just how bad are the numbers? Well, 2010 was the last five-year peak, which totaled 27,550 cases. It’s currently September of 2012, and the numbers last reported to the CDC were at 29,834, and that doesn’t even include over 3,700 cases in Minnesota that haven’t been officially reported to the CDC yet. These numbers, which include 14 deaths (primarily of babies under 3 months), may very well end up doubling the 2011 total of 18,719 if they continue at the current rate through the end of the year. It’s the biggest pertussis outbreak since 1959.
Not surprisingly, the majority of the states leading in pertussis cases are also among those that offer personal belief exemptions. Washington, despite their new law, is sitting at 4,190 cases, quadrupling their 2011 count of 965. This is the state where 7.6 percent of parents opted for exemptions (among all grade levels, not just kindergarten) in 2008-09, more than four times the national rate of about 1.5 percent. Minnesota and Wisconsin have similarly high rates and both have personal belief exemptions. The most recent numbers out of Minnesota are 3,748 — they had just 661 cases last year. Wisconsin is leading the nation with 4,640 cases, up from 1,192 in 2011, at last report in the Sept. 28 Morbidity and Mortality Weekly Report (pdf) at the CDC.
But the increases are being seen across the nation, as this CDC map shows. Texas (1,287 cases to date this year), Pennsylvania (1,428 cases) and Colorado (897 cases, though they averaged 158 over the past four years) are among other states with personal belief exemptions (though the Texas one has significant restrictions and hoops to jump through). But it’s clear the decreased effectiveness of the vaccine is playing the biggest role, especially in places like Iowa (1,168 cases) and New York (2,107), neither of which offer personal belief exemptions.
Again, though, a less effective vaccine does not mean a worthless vaccine. It still offers 85 percent protection when you get the shot or the booster, and even as it loses some effectiveness as the years go by, you’re far less likely to have a severe case if you do get the disease. And you’re protecting those around you, including the babies who have only been here a few months and are the most susceptible to catching and dying from the disease.
Bottom line — it’s worth it to get the shot, and to make sure your kids do too.
Opinions expressed in this article do not either necessarily reflect or conflict with those of the DXS editorial team or contributors.
[Tara Haelle (www.tarahaelle.com) is a health and science writer and a photojournalist based in Peoria, IL after years as a Texan, where she earned her undergraduate degrees and MA in journalism at UT-Austin. She’s the mental health editor for dailyRx.com in addition to reporting on pediatrics, vaccines, sleep, parenting, prenatal care and obesity. Her blog, Red Wine & Apple Sauce, focuses on health and science news for moms, and you can follow her on Twitter at @health_reporter and @tarasue. She’s also swum with 9 different species of sharks, climbed Kilimanjaro and backpacked in over 40 countries, but that was in the years of B.C. (Before Children). She finds that two-year-olds are tougher to tussle with than tiger sharks.]
An infant girl suffering from pertussis, a vaccine-preventable disease, struggles to breathe. Those indentations in her ribs are one of the signs of her extreme difficulty drawing breath. Via CDC.
What’s not to fear directly about vaccines? There’s a needle that someone pokes into your child. Your child screams. You tense up. What’s in there? you wonder. Viral or bacterial bits that, in ways that are mysterious to a non-immunologist, will keep your child well when intuition seems to say they ought to make your child sick.
Needles, screaming, microbial bits…these naturally would make any parent blanch. The number of vaccines has added to the fear for at least a decade, leading to non–evidence-based calls to “spread out” the schedule or reduce the number of vaccinations.
In fact, the evidence supports the schedule as it’s recommended.
The fear of vaccination is not new. Since Edward Jenner and his cowpox inoculation at the turn of the 19th century, people have latched onto the fear of the known—those needles!—and unknown—what’s in those things?
What might be considered the first anti-vaccine cartoon appeared in response to Jenner’s proposed inoculation of cowpox to combat smallpox.
The vision of cows growing out of arms is comical, but the reality of possible side effects from today’s vaccines can lead some parents to keep their children away from the doctor’s office. Indeed, this anxiety has done so since the days of the 19th century anti-vaccination leagues, aligned against the widespread use of Jenner’s smallpox vaccine.
The vaccine wars in those days were just as bitter and divisive as they are today, including an 1885 march in England in which anti-vaccination forces carried a child’s coffin and an effigy of Jenner himself. Today’s most fanatical crusaders against vaccines may not carry coffins or effigies, but death threats against those who promote vaccines for public health are not unknown.
The fact that the vast majority of parents overcame those fears and had their children vaccinated has led to some of the greatest public health successes of the 20th century. Thanks to the willingness of people to participate in vaccination programs, smallpox disappeared and polio became a thing of the past in much of the world. Indeed, people in those eras knew, often from personal experience, what these diseases could do—maim and kill—and the fear of those very real outcomes outweighed fears of the vaccinations.
But today, we’re different. In the United States, most of us under a certain age have never witnessed a death from diphtheria or tetanus or smallpox or measles. We haven’t seen a child drained of life as a rotavirus rapidly depletes the molecules she needs to live. Many of us have not witnessed the sounds of pertussis, the vomiting, the exploding lungs in an agony of infant death. Why? Because of vaccines.
This very success has, ironically, led to the resurgence of fear and misgiving about vaccines. No longer weighed against anxiety of death or disability from disease, the fear of vaccines now aligns against the bright picture of a nation of children largely free of life-threatening illness.
Without the collective memory of days when children played on the playground one day and died the next of vaccine-preventable disease, the calculus of parental fear pits only the side effects of vaccines against the healthy child. Vaccination requires intentional agency—parental agreement—to impose on that healthy child the very small risk that vaccines carry. Some parents simply are not comfortable either with that intentionality or that risk.
Feeding this reluctance is the explosion of Internet sites that warn against vaccines or disseminate incorrect information about them. The Centers for Disease Control and Prevention (CDC) has provided abundant information about vaccines, including a page devoted to countering erroneous information with facts.
This information will not move the fiercest anti-vaccine groups that lump the CDC in with pharmaceutical companies and others in an alleged conspiracy to harm millions via a money-making vaccine industry. However, it certainly helps concerned parents who simply seek to calm fears, weigh evidence, and make an informed decision about choosing vaccines over the life-threatening illness and compromised public health that result when people don’t vaccinate.
Indeed, these threats to public health have grown considerably with recent large outbreaks of measles and pertussis, including a growing measles outbreak in Europe involving more than 26,000 cases of measles, more than 7000 hospitalizations, and nine deaths as of this writing. The growing threat has led to calls for more stringent requirements for childhood vaccines, including dropping exemptions and requiring that all children be vaccinated over parental objections. This tactic likely would increase vaccination rates among children attending school.
But instead of strong-arming parents into having their children vaccinated, what we really need is a two-fold approach to education. First, we need sober, non-sensationalist reporting from the news media about vaccine-related stories, including stories about side effects, research, and court cases. These articles—and their sensational headlines—are in all likelihood among the prime drivers of the rumor mill against vaccines.
Second, when parents read these stories and turn to a medical professional for input, that input must come as part of a two-way communication between the health professional and the parent, not in lecture format or as patronizing. A little, “I understand your concerns because I’ve had them, too, but here’s what I know that gives me confidence in vaccines,” is considerably better than, “Your child has to be vaccinated, or you can get out of my office.” The onus is on parents to ask with open minds and an understanding that the medical professional in front of them has likely devoted considerable time to gaining the education and expertise necessary to address their questions. Health care isn’t a competition about who knows more. It’s about evidence-based health practices.
As centuries of history attest, no efforts will completely eradicate vaccine fears. Motivations fueling anti-vaccine sentiment that go beyond information gaps range from personal economic benefit to a desire to out-expert the experts to the inertia of fear.
But a careful and persistent information campaign and outreach efforts from medical professionals in the trenches may help keep vaccination rates sufficiently high. Parental investment in gaining information from trained professionals and making decisions based on facts rather than fear is also an indispensable component. To ensure adequate rates requires either these efforts or a resurgence of the deadly diseases that have graphically demonstrated the real balance of the threats at issue here.
Which one would we rather have?
Emily Willingham, Double X Science Editor Twitter, @ejwillingham ———————————————————————— A version of this post originally appeared on the blog of PKIDs, Parents of Kids with Infectious Diseases. The mission of PKIDs includes educating the public about infectious diseases and methods of prevention and transmission. Follow PKIDs on Twitter @PKIDs.
The flu season that is unfolding is a killer, with influenza having already taken dozens of lives across the United States. Deaths from flu during the flu seasons are actually the norm, ranging from 3000 to 50,000 annually, but this year’s outbreak arrived early and features a strain that is infamous for its virulence. Forty-four states now have met the cutoff for “widespread” flu activity as of this writing, and in hotspots like Boston, MA, cases are 10 times the number from the same time last year. In many areas, hospitals have taken to setting up temporary tent shelters outside the buildings to manage the flood of cases and prevent spread inside the facility. ETA: This USA Today article gives an overview of how clinicians are experiencing this outbreak on the ground. [Update: As of 1/18/13, a total of 48 states are now at widespread status, and 29 children have died. Forty percent of hospitalized children have had no known underlying medical conditions.]
Public health officials from the US Food and Drug Administration and the Centers for Disease Control and Prevention(CDC) are urging people who have not gotten their flu shots to do so, saying that there is still time for the vaccination to work for you against the flu. The most vulnerable population is children, and 18 children have already died in the United States during this year’s season. According to reports, far less than half of the eligible population in the US has gotten a flu vaccination.
People express reluctance to get the flu vaccine for several reasons. Among them are fears that the vaccine contains mercury as part of a preservative, thimerosal, that has been used for years in various immunizations, although it’s been removed from many. For the flu, only vaccines from multidose vials contain this preservative, which is needed to protect the contents from contamination when the vials are opened for repeated use. Single-dose shots and the inhaled Flu Mist do not contain this preservative, which an abundance of studies have shown does not cause harm despite diligent efforts from anti-vaccine organizations to argue otherwise. For more information about this preservative in multidose vials of flu vaccines, the CDC offers a Q&A.
Another source of reluctance is the fact that the flu vaccine, like several other vaccines–or indeed, having the infection itself–is not 100% protective against the illness. In fact, it appears to be about 60% effective in preventing illness, although those who have been vaccinated and do fall ill with the strain included in the vaccine might experience less intense symptoms. The CDC also offers a Q&A addressing why some people who have been vaccinated still catch the flu. My personal feeling is that I’d rather give my children that 60% chance in a rampant flu season with a virulent strain that’s hospitalized tens of thousands than give them no protection at all. Any number of interventions don’t carry a 100% guarantee of effectiveness, but they certainly enhance the favorable odds. My children and I all received the Flu Mist vaccine back in October. ETA: A recent report found that different forms of the vaccine have different levels of effectiveness in different age groups and that the vaccines and vaccine program require improvement. For more information about the report, which concluded as we’ve written here that flu vaccines offer moderate protection and have a good safety profile, please see this post by an epidemiologist.
People also forgo a shot because they think that only people in poor health or with pre-existing conditions are susceptible to the most dreaded outcomes with flu: hospitalization and death. That’s not actually the case. “Influenza” is the name we give to the highly variable viruses that play games of genetic mix-and-match in different species, with results that are unpredictable and rapidly changing. No one’s previous experience with flu will necessarily be predictive of later experiences with the virus. Some flu strains do hit certain populations with specific existing health problems, but other strains kill the young and healthy preferentially. And whether or not you yourself are in perfect health, if you get the flu, you risk passing it along to someone who is not. ETA: For a personal look at who some of those people are, please see the Faces of Influenza site. Some people cannot get a flu shot for medical reasons, and anyone who has had a reaction to a vaccine should obviously consult with their medical professional about vaccines.
A final source of reluctance is that the flu vaccine each year is developed based on educated guesses. No one can predict with certainty which strains will gain the upper hand. As it happens, one strain in circulation this year falls outside of the vaccine target, but medical authorities report that so far, 91% of strains identified in circulation are targets of the vaccine. Because we are talking about influenza and several circulating strains, if you do not get a vaccination, it’s entirely possible for influenza viruses to hit you or your family hard more than once this flu season.
Bottom line? Without a vaccination, you’re 100% exposed no matter what your age, health, diet, exercise routine, or supplement intake. And if you get sick, you’ll endanger everyone you’ve been around and contaminate every place you’ve been. Flu carries innumerable potential and unpredictable outcomes, from complete recovery to death, and hospitalizations this year are extremely high. People with a genuine case of influenza end up floored for days, in body-wide pain, with high fevers and wracking coughs and a risk for pneumonia, hospitalization, and death, sometimes with unpredictable rapid progression. Even for those who don’t end up in the hospital, complete recovery from these deadly and unpredictable viruses typically takes weeks, meaning lost school, lost productivity, lost work, lost wages. Meanwhile, the vaccine cost ranges from free to about 20-40 bucks at various pharmacies.
Here is a basic video explaining some of the complexities of the flu vaccine and its success rate:
The opinions expressed in this article do not necessarily reflect or conflict with those of the DXS editorial team or contributors.