Getting Religion about Vaccines

Herd Immunity?

As the current measles epidemic continues unabated, many are looking for explanations. One obvious target are the religious and personal belief exemptions that have allowed for increasing pediatric undervaccination. Yet the fact that many states and other entities allow religious exemptions might suggest that most religions object to vaccines. Miriam Krule writing in Slate explodes the myth of religious exemptions and describes how despite few true exemptions, it is very easy to claim one.

Her conclusions:

"The only two religions that have any possible negative stance (though it’s not even clear that they do) on vaccination are Christian Scientists and the Dutch Reformed Church."

"In order to apply for a religious exemption, you don’t even need to be religious. If you live in Connecticut, for example, all you have to do is fill out this incredibly simple form... In Florida, all that is needed is the child’s name, date of birth, and social security number—no proof of religion, or even name of a religion, is needed."

Irrespective of the lack of formal religious exemptions, when we speak with parents as physicians or public health officials, we need to be aware that three existing vaccines (hepatitis A, rubella, chicken pox) were developed from cell lines derived from aborted fetuses. For this reason, some Catholic and other parents might refuse to vaccinate their children. However, this issue has been well studied by the National Catholic Bioethics Center and the Pontifical Academy for Life who "have determined that it is morally licit, and even morally responsible, for Catholics to use even those vaccines developed from aborted fetus cells."

Dr. Paul Cieslak in the Catholic EWTN news states "While the new measles cases are cause for concern, the outbreak isn’t nearly as bad as it could be, and that is thanks to vaccinations. The fact that it doesn’t spread to everybody is a testimony to the fact that most of them [who were exposed] are immune, and most of them got that way through vaccinations. And when we have seen transmission of multiple cases, it has been largely among unvaccinated people. As a Catholic, I would argue that it [vaccination] is a socially conscious thing to do. It’s not only good for you, it’s good for your fellow man."

Media False-equivalency and the Disneyland Measles Outbreak

Many of us have watched from the sidelines as the anti-vaccine and other science-denier movements have grown through the explicit and implicit support of large media corporations. Even if 99% of scientists support the safety of vaccines, a false balance gives the anti-vax view equal time. Others have written eloquently on false-equivalency in the media and how this anti-science attitude endangers public health. There is no better example of the misguided media support of anti-science than anti-vaccine torchbearer Jenny McCarthy. Since 2007, she has made numerous false claims about vaccines on Oprah, Good Morning America and other venues. One need only to read Michael Specter in the New Yorker (2013):

Jenny McCarthy, who will join “The View” in September, will be the show’s first co-host whose dangerous views on childhood vaccination may—if only indirectly—have contributed to the sickness and death of people throughout the Western world. (See jennymccarthybodycount.com.) McCarthy, who is savvy, telegenic, and pulchritudinous, is also the person most visibly associated with the deadly and authoritatively discredited anti-vaccine movement in the United States. She is not subtle: McCarthy once essentially threatened the actress Amanda Peet, who has often spoken out about the obvious benefits of childhood vaccinations, by warning Peet that she had an angry mob on her side. When people disagree with her views on television, McCarthy has been known to refute scientific data by shouting “bullshit.”

While McCarthy's 1-year stint on "The View" has now ended, she now appears annually on "Dick Clark's New Year's Rockin' Eve with Ryan Seacrest." FYI, we're considering changing the blog name to Dan Diekema's Controversies in Infection Prevention with Mike and Eli. Parsimony is so 2014.

In addition to implicit support of anti-vax folks, there are many other examples of corporate support for anti-science beliefs. For example, in November Curt Schilling (ESPN analyst and former pitcher) took to Twitter to rail against evolution. In the wild-west that is social media, ESPN baseball writer Keith Law quickly responded with a defense of evolution and science in general. As you can imagine, only one of the ESPN "discussants" was suspended - science supporter Keith Law.

So why mention these specific examples, as there is nothing surprising about ESPN backing an ex-baseball player over a writer? The irony is that The Walt Disney Corporation owns ABC (The View, Dick Clark, Good Morning America) and ESPN. And of course Disney owns Disneyland where a seven-state outbreak of measles with at least 85 cases began. While it might be true that select anti-vax folks remain "unmoved" by the latest outbreak (it's their right to decide what eliminated diseases come roaring back), this outbreak might awaken media corporations with large amusement parks to the downside of anti-vax false equivalency. It can't help the bottom line and public image of Disney that scared parents and public health officials are recommending calling off trips to the park.

One might feel a bit sorry for Disney if they hadn't played some role in setting the stage for this and other vaccine-preventable outbreaks. However, my main concern is for the many children too young to receive the vaccine or those with suppressed immune systems whose herd-immunity shield has been needlessly laid down. "It's a Small World" will never sound the same.

No spring break for measles

If you’re a regular reader, you may have noticed the blog has been on break for a little while. While I was trying to relax with my morning coffee last week in Sarasota, I kept running across reports of measles outbreaks in New York City, British Columbia, and California. As usual, these outbreaks can be sourced to those who refuse immunizations, perhaps because of long-discredited fears about autism, or (as in the case of the BC outbreak) because they are getting confusing messages from the person who speaks for their deity. 

I have nothing to add to this commentary by a New England pediatrician, which refers to a depressing study out of Dartmouth that suggests our current messaging around vaccine acceptance is ineffective. For a great recent example of good messaging, see this post by Tara Smith, entitled, “Why I vaccinate my kids”.

But if factual, rational messages fail to sway vaccine deniers, what other options are available? How to respond, for example, to those who base their vaccine denial on religion? So I spent the better part of my time away in prayer and meditation, seeking revelations from all the major deities. I’m happy to announce that they all were in favor of immunization. The main point each of them made to me (aside from pointing out that all the others I communicated with were false deities, not worthy of my time), was that they gave humans an astonishing intelligence and reasoning capacity for a purpose. 

Thus I implore you to go forth and get immunized. The only true god of your choice commands it.

Attending Super Bowl after refusing super-effective vaccine is super-stupid

Not much new to say about this that we haven’t already covered. If vaccine refusal becomes increasingly prevalent, imagine the consequences when highly communicable viruses meet hundreds of thousands of congregating susceptible hosts.

I’ll outsource my outrage to Charles Pierce.

h/t to our regular reader Noel Eldridge for linking us to the Slate piece on this.

MMWR - Field notes from the Minnesota measles outbreak

Dan posted last week on the ongoing measles outbreak in Minnesota and he provided many links to useful resources.  Today the MMWR published a "Notes from the Field" that summarizes the 13 epidemiologically linked cases that have been identified as of April 1.  Five children were too young to receive the MMR. 

Measles in Minnesota

So there is another measles outbreak, this time in Minnesota. Unlike recent experience with mumps, in which outbreaks are associated with vaccine failure (over 60% of cases occurring among recipients of two mumps vaccines), measles outbreaks occur primarily among the unvaccinated, and are sustained by those who reject or avoid the MMR (see prior posts here and here). Of the 13 confirmed Minnesota cases, 5 were too young to be vaccinated, 6 should have been vaccinated but were not, and 2 so far are of unknown vaccine status. Regular updates can be found on the Minnesota Department of Health website. There’s also an interesting article in the Star-Tribune about resistance in the local Somali community to receipt of MMR, out of fears of….you guessed it, autism.

We’ve covered this ground before—go here for our prior posts on the anti-vaccine movement. We recently had some local news coverage of a pediatrician who was declining patients if the parents refused vaccinations. I believe this is a perfectly reasonable position for a pediatrician to take. In fact, if a pediatrician does accept anti-vaccine families, he or she has a duty to warn all the other patients in the practice of the increased risk to infants or immunocompromised children from being in that office waiting room.

Don't wait in a doctor's waiting room

I should have said don't wait too long in the "waiting area of healthcare premises" especially if another occupant/patient has measles, as the authors of a new study in BMC Infectious Diseases report.  The authors analyzed the likelihood of acquiring TB, influenza or measles during stays of 30 or 60 minutes in a standard waiting room using a mathematical model simulation.  One caveat is that they assumed one person in the waiting room was infectious with one of the organisms. Thus, while the results provide nice theoretical estimates of airborne transmission for these highly (measles), moderately (influenza) and minimally (TB) infectious organisms, they don't adjust for the probability of an occupant having the infection in the first place (influenza>TB>measles).   

With that important caveat, the likelihood of acquiring TB during a 30 minute stay in a waiting room was 0.3% and was 0.8% for a 60 minute stay.  For influenza, the numbers were 2.6% and 6.6% at 30 and 60 minutes and were 13% and 31% for measles.  With those numbers, if there is measles in the community at all, it's probably best to avoid any waiting area (unless you've been vaccinated). Nothing surprising in the results, really, but still worth quantifying and thinking about.  During the H1N1 season last year, I was always worried about transmission in the various hospital waiting areas.  In those situations, it was likely that >1 person had infectious influenza in the waiting room.  I hope future studies analyze the impact of # of infectious occupants and likelihood of those infectious occupants being present during various seasons (RSV, Influenza etc).

Once last thought.  Next time a clinician keeps you waiting, you might mention that he/she has put you at increased risk for getting sick.


Beggs et al. BMC ID article

Measles more measles

It has been almost a year since our last posts on measles (here and here). Now there is a report out from NPR concerning a 16-person outbreak in Vancouver associated with the Olympics. Half of the cases are reportedly in a family who rejected vaccination; apparently a large family at that. There is also a report out in Pediatrics of the 2008 San Diego outbreak whose index child acquired it in Switzerland, which has a lower than 95% level of vaccination required for herd immunity to measles. The San Diego outbreak resulted in 839 exposures and 11 additional cases. Of the 839, 73 were not vaccinated and 48 of those were too young (less than 1) to be vaccinated. That's why herd immunity (or vaccination rates >95%) are so important, since the infants can't be protected with vaccination. The remaining 25 had parents that refused vaccination. I didn't realize that Switzerland had such low vaccination rates.

Think about all of the money spent to track and then treat the contacts and cases in these outbreaks, and the needless suffering. It's too bad we can't charge those that intentionally don't vaccinate their kids if their kids spread disease. I'm not sure how you would do that. You have to pay taxes for fire and police and the army (mandated), you have to have auto insurance to drive a car and we may even need to have health insurance here soon, but you still don't have to get a measles vaccine to breathe on an infant!

More Measles

Following on Mike’s post about measles in Maryland, we now also have reports of measles from Pennsylvania and from my state of Iowa.  Ugh.  If you are interested, you can read the details of the last big measles scare in my state (focusing on the overall costs of the public health response to a single case).  My fondest memory from that 2004 episode was spending a long weekend afternoon in our emergency department while a child with a compatible clinical illness was being evaluated--compiling exposure lists, reassuring healthcare workers, and communicating with our on-call state epidemiologist about setting up vaccine clinics.

Details are still emerging, but the Pennsylvania cases appear to be associated with unvaccinated children, the common theme in these situations (lack of vaccination, that is).