Who is to blame for all the measles?

There’s a massive outbreak of measles underway in China. It’s big, really big:

“In the first five months of 2014, China has reported nearly 36,000 cases of measles, well over the 27,646 cases reported for all of 2013 and almost six times the number reported in 2012.”

In a country with that many people (over 1.3 billion at last count), 36 thousand cases may not seem like a lot. It’s 0.003%, but remember that we don’t do math that way in epidemiology. We divide 36,000 by the number at risk, and the number at risk is indicated by the number who are not vaccinated or have lost their immunity due to disease (e.g. cancer) or treatment for a disease (e.g. cancer, again). That number, the number at risk, is pretty much uncertain because the public health infrastructure in China is, well, lacking.

But this post is not about China. It’s about the good ol’ US of A. We have a somewhat robust public health system that, in my humble opinion and when it comes to immunization, is probably up there with the best in the world. There is no child in this country that does not have access to immunizations. If you have a child in the most remote corners of this country, you can get them vaccinated at little to no cost, especially against the killers like whooping cough and measles. So why do we have measles making a comeback here in the US? Is it just the anti-vaccine crew that have done this to us? (Don’t be fooled, it is us, you and me, that will be affected if vaccine-preventable diseases make a comeback.)

Yes and no. I’ve been reading some blog posts by some very well-intentioned people, and they place all of the blame on vaccine refusers for the rise in measles that we are seeing. I read a lot of that hand-wringing in those posts. After all, anti-vaxxers are the natural enemy of vaccine supporters, right? It’s the Jenny McCarthys and Andrew Jeremy Wakefields and their followers who we must fight and fight some more, so why not blame them (and them alone) for the rise in measles, mumps, and whooping cough?

We can’t just blame them and them alone because this is a very complex issue. The federal and state governments also have some fault because they’ve made enforcing vaccination requirements a joke. There are states that allow parents to simply sign a form to let their unvaccinated disease incubators go to school. Other states allow religious exemptions though there are no actual religions that prohibit vaccination. (Maybe some of the newer, whackier religions?) And don’t get me started on the under-funding of public health overall. If I had to decide whether to enforce vaccine requirements or inspect foods, which would I do?

The educational system is also to blame because it has failed to give today’s parents the tools they need to discern between good and bad science. Very basic teachings in biology, chemistry, and math would allow people to tell that what they’re being told by anti-vaccine outfits are out-of-context facts at best and outright lies at worst. Biology would help them understand why “leaky gut,” viral shedding, and all the other things attributed to vaccines are crap science. Chemistry would help them understand why thiomersal is not “mercury” like anti-vaccine advocates would like you to think that it is. Math would help them understand things like odds ratios and relative risks.

Then there’s the media. Their continuing attempts at false balance by giving equal time to quacks when discussing vaccines confuses the unknowing, uneducated public. A hysterical anti-vaccine advocate who doesn’t let a medical doctor speak and just drones on and on about all the evil things that vaccines are believed to do is actually credible to some people. Some people want to believe, and when they see that credible news outlets invite anti-vaccine nuts, well, then their belief is confirmed.

I would love to just point the finger at outfits like NVIC and AoA and say that they’re to blame for all the measles. Heck, if it was only Andrew Jeremy Wakefield that did this to us, the solution would be simple. But the problem is huge and complex, and we pro-vaccine bloggers are not doing our audience any favors by just saying that it’s the anti-vaxxers and leaving it at that. After all, what kind of action can you take against someone with such closely-held beliefs? You can’t really change a person at that deep a level. But, if we realize that there are other causes that we can do something about, then we can, you know, do something.

Oh, and we’re a plane trip away from China and from a fresh pool of measles to land on us… That’s why I mentioned China. I almost forgot.


But Hepatitis A is a disease of the unclean! WTF?!

It was a little over a year ago that I told you what the National Vaccine Information Center had to say about hepatitis A. Oh, yes, they do mention that you can contract Hepatitis A through contaminated food, but they seem to make a special effort to tell you that you’re okay in the good old USA:

“Hepatitis A is spread almost exclusively by the fecal-oral route and is most often associated with poor sanitation and hygiene, and overcrowded living conditions.

It also is associated with lower socioeconomic status, certain sexual practices, and injected drug use. However, outbreaks of hepatitis A have also occurred in restaurants, daycare centers, nursing homes, and other institutions and community settings.

Some outbreaks of hepatitis A have been traced to contaminated food, water, milk, frozen raspberries and strawberries, and shellfish.

Among adults with identified risk factors, the majority of cases are among men who have sex with men, persons who use illegal drugs, and international travelers. Because transmission of hepatitis A during sexual activity probably occurs because of fecal-oral contact, measures typically used to prevent the transmission of other STDs (e.g., use of condoms) do not prevent hepatitis A transmission.

Hepatitis A infections also have been linked to children adopted from certain countries.”

Those damned immigrant children! Oh, and this:

“Poor personal hygiene can increase the chances of spreading hepatitis A. That is why frequent hand washing with soap and water, particularly after using the bathroom, changing a diaper, and before preparing or eating food, is very important in preventing the spread of hepatitis A.

It also has been identified as a risk factor in daycare centers and intensive care neonatal units.

Travel to Third World countries, where hepatitis A is more prevalent, also is an identified risk factor for getting this infection.”

They seem to be obsessed with third world countries. While it is true that there is a higher incidence of Hep A in third world countries, there is also plenty of Hep A to go around here in the States. But have no fear, there is a vaccine, and this is what that USA Today article has to say about the vaccine and the current outbreak:

“Of the 79 people in seven states who have become ill with the deadly liver disease, only one was a child. Health officials initially feared that the youngest would be hit hardest because the contaminated frozen berries are used in smoothies, popsicles and other warm-weather treats popular among children.

They credit routine vaccinations against hepatitis A since 2006 with protecting children.

“The very, very small number of children involved in this outbreak probably reflects the high vaccination coverage as the result of the routine immunization,” said John Ward, who directs the viral hepatitis program at Centers for Disease Control and Prevention (CDC).

The one child who did become ill, a 2-year-old, was not vaccinated, Ward said.”

Imagine that. A vaccine that works, is safe, and can keep children safe from an unneeded medical condition. (Not that there is a “needed” medical condition, but anti-vaxxers will tell you that you “need” chickenpox and measles to make you “stronger.”) Of course, I can play Devil’s Advocate and tell you that children are more likely to be asymptomatic. So you’re less likely to pick up cases of children being sick. BUT you’d see the symptomatic adults that take care of those children. That’s the catch. That’s where the misinformation dealers try to trick you.

I can’t tell you my sources, of course, but those adult cases right now have had children in the household tested, and they’re negative for hepatitis A IgM, the antibody indicator of acute infection. They’re also negative for Hep A virus in the stool. Imagine that.

Of course, leave it up to NVIC to tell you that the vaccine is horrible:

“There is a gap in medical knowledge in terms of predicting who will have an adverse reaction to the hepatitis A vaccine and who will not.

However, reading the manufacturer’s product package inserts (see below) under “contraindications, warnings and precautions, and adverse reactions,” will help you weigh the vaccine’s benefits and risks before making a decision for yourself or your child.

Within the hepatitis A manufacturers’ vaccine package inserts, some of the adverse events reported ranged from fever, to nausea and loss of appetite, to dizziness, and neuromuscular symptoms, including Guillian Barre Syndrome.

According to the CDC, some of the other risks and side effects from this vaccine are:

Mild problems

  • Soreness where the shot was given (about 1 out of 2 adults, and up to 1 out of 6 children)
  • Headache (about 1 out of 6 adults and 1 out of 25 children)
  • Loss of appetite (about 1 out of 12 children)
  • Tiredness (about 1 out of 14 adults)
  • If these problems occur, they usually last 1 or 2 days.

Severe problems

  • Serious allergic reaction, within a few minutes to a few hours of the shot (very rare)”

I bolded and underlined the part about the vaccine package insert because it’s a common ploy of the anti-vaccine groups. See, the manufacturers need to put in the inserts those things that were reported during vaccine trials, whether they happened as a cause of the vaccine or not. If someone caught the flu during the trials, guess what? You have to put in there that “fever” or “nausea” was reported. Guillain-Barre Syndrome happens on it’s own in 1 out of 1,000,000 people, so they would have had to put that on the vaccine insert if one of the people during the trial got it. Furthermore, they need to put in the insert anything that happens after it’s licensed and it’s causally associated with the vaccine. There have been no cases of GBS causally associated with the vaccine, and people who get the vaccine are not at a higher risk for GBS.

So what do we have here? We have an outbreak of hepatitis A in the United States of America, the world’s lone superpower (as long as you don’t tell the Chinese). We’re clean, we wash our hands, and we screen our “third world babies” when we adopt them. (And, in Texas, we don’t have men who have sex with men. [Yeah, we do.])  In that outbreak, one child has been confirmed as a case, and that child was not vaccinated. The vaccinated children in the household of cases tested so far are not sick, and not even infectious (no virus in stool).

One of my colleagues said the other day that people who handle food, from the farm to the plate, should be required to get the Hep A vaccine. I completely agree. Since most of the cases in the US are primarily associated to contaminated food, this would seriously cut down on the number of outbreaks. However, I would go one step further and vaccinate all inmates as they are incarcerated, anyone who has liver disease, and all children, so they don’t pass it on to unsuspecting adults in their family or to other children in their schools.

After all, the benefits outweigh the risks.

The many and the individuals

The thing about public health and public health workers is that we are not healthcare providers in the strictest sense. While some of us may be nurses, physicians, or physician assistants, most of us never even come into direct contact with the people we’re serving. Even those who do “treat” people, e.g. give a vaccine or administer post-exposure antibiotics, are not in charge of the continuing care of the individuals. On the one hand, we’re protecting the health of the people. On the other, it’s not entirely up to us.

This causes some friction, especially when a provider thinks that he or she should be the final arbiter of what to do with their patients. Take, for example, a certain pediatrician to the stars. This pediatrician has said over and over that his decades of experience in medicine and his gut feelings dictate his approach to immunizations. He believes that some vaccines undoubtedly cause bad things, and that vaccines should be spaced out as much as possible, if they are to be given at all.

For his individual patients, that’s fine. It’s really between he and his patients how he is to tend to their healthcare needs, so long as he practices a standard of care that is not negligent and does so in the best interest of his patients. However, for the population at large, this is not a good thing. It’s not good to erode herd immunity against things like measles or mumps. It’s not good under any circumstance.

There was once a kid in a very large university who came down with bacterial meningitis. He had been at a party and allegedly “hooked up” with several young women that night. We did our best to track down those contacts, and everyone else at the party. When we did, we notified them of a possible exposure to bacterial meningitis, and we advices them to go into their local health department to be given antibiotics or to go see the university’s health providers, or to go see their own physician. Well, there was one physician who saw one of the young ladies in question and refused to give her antibiotics. He said that she said that the case and her never really hooked up. They just sat on a bed in a room at the house where the party happened and talked, nothing more. So the physician took her word for it.

This triggered a huge discussion on what to do with her. Would we ask the physician at the local health department to give her the antibiotics anyway? Would we respect her physician’s decision, albeit a questionable decision? What to do?

In the end, the local health department staff reached out to her and explained to her the situation. She was told that she could be in danger if there was any chance that she and the case shared any spit, even incidentally, at the party. (He had fallen most ill about a day after that party, so he was very infectious when he went to it.) She opted not to chance it. Days later, her physician apparently complained about being overruled.

And that’s not the only example I’ve seen or heard of where private practice providers clash with public health practitioners and workers. It seems to be a constant struggle. I don’t see it as a bad thing, though. There must be an interest in providers to take care of their patients, even if jealously so. And the must be a willingness of public health workers to do their due diligence, even if that means stepping on the toes of private practitioners. All as long as we’re all doing it in the best interest of the patient.

So how do we deal with people who refuse vaccines even though they’re licensed healthcare providers who should know better? Or those who refuse to give vaccines and whose action, or inaction, may lead to an outbreak of a serious disease in the community?

I don’t know. It’s above my paygrade to figure out those things. But I have passed this discussion on to a friend who is about to enter a Doctor of Public Health program. I hope his education in that program covers these issues because we need answers. We need guidance. We need to figure out who supersedes whom when it comes to serious disagreements like vaccines, fluoridation, or even antibiotic use.

I’d like to say that evidence supersedes all personal or professional opinions, but the world doesn’t work that way, sadly. In this world, we need to deal with each other, work with each other, and do it all in the best interest of the public and their health.