Posts Tagged ‘measles’

Vaccination/immunization: part 1 Kids first

Sunday, February 10th, 2013

I was reading an Annals of Internal Medicine update on adult immunizations and then found it was available for the general public on a CDC website. I thought we were pretty much caught up on our own vaccinations, but decided to read the article anyways. There are, as always, some changes and I'll eventually walk through those for you.

He's up to date with his vaccinations; some others aren't

But that's not the real issue in America today. A piece in The Wall Street Journal on Feb 6, 2013 with the title "Rolling Back the War on Vaccines is dead center on. The authors are Jay Winsten, an associate dean at the Harvard School of Public Health and Emily Serazin, a principal of the Boston Consulting group, (a global management consulting firm with 77 offices in 42 countries) and they sound a very loud alarm, primarily for those with small children.

We still have too many kids who aren't vaccinated and as a country we stand in danger of losing "herd immunity," and in doing so, endangering our youth. There have already been several resultant epidemics here and elsewhere; measles in Europe in 2011 affected >30,000 and the U.S. had 222 cases, primarily linked to those who had traveled to Europe. If you look worldwide, away from places where vaccination is routine, measles killed 139,300 people in 2010.

And then there's pertussis, AKA whooping cough. A July 19, 2012 CBC News report noted that the number of U.S. pertussis cases had doubled, 18,000 at that point, with nine children dying as a result. Kids who haven't been vaccinated are eight times as likely to get pertussis, according to a CDC physician.

The Institute of Medicine (IOM) issued a January 2013 report on childhood immunizations in the United States. I knew there was such an organization, but wasn't clear as to what is was and how much credence all of us should pay to its pronouncements, so decided to read further.

The IOM is an American non-profit, non-governmental organization, founded in 1970 under the congressional charter of the National Academy of Sciences. Its purpose is to provide national advice on issues relating to biomedical science, medicine, and health, and to serve as adviser to the nation to improve health. It works outside the framework of the U.S. federal government to provide independent guidance and analysis and relies on a volunteer workforce of scientists and other experts, operating under a rigorous, formal peer-review system.

IOM committees are carefully composed to assure the requisite expertise and to avoid bias or conflict of interest. Every report produced by IOM committees undergoes extensive review and evaluation by a group of external experts who are anonymous to the committee, and whose names are revealed only once the study is published.

The summary of the IOM's report on The Childhood Immunization Schedule and Safety, with its subtitle being Stakeholder Concerns, Scientific Evidence, and Future Studies mentions that vaccines are one of the safest and most effective public health interventions available.

As a result of their effectiveness, with smallpox totally unknown as the killer it once was, measles rare in America and other diseases reduced or virtually extinct, parents of kids under five, now worry more about vaccines than the diseases they so successfully prevent. Some would deny their children the proven benefits of immunizations because of the schedule of 24 injections by age two (as many as five at one time), others for religious reasons, potential harm from side effects or mistrust of our government. Their fears are inflamed by those who, for varying reasons, inveigh against any vaccinations.

The IOM panel concluded that a prospective randomized, controlled study would not be ethical, and since fewer than one percent of all Americans refuse all immunizations, a new observational study (comparing outcomes between those kids who are vaccinated and those who aren't) would be prohibitively difficult and time-consuming. In order for such a research study to be valid, the kids would need to be matched pairs of the same age, sex, ethnicity and location in the U.S..

So the best approach appears to be one that uses the Vaccine Safety Datalink (VSD), a twenty-three-year-old project linking the CDC with nine managed care organizations. It's a well-proven tool for evaluating the safety of immunizations. The VSD could be adapted for further studies to address stakeholder (parents and others) concerns.

The scales of justice are available when needed

The U.S. has a National Vaccine Injury Compensation Program (NVICP), in part started as a result of the anti-vaccination movement. The VCIP's goals are to ensure an adequate supply of vaccines, stabilize their costs and act as an accessible/efficient modality for people actually found to be injured by vaccines. A designated section of the U.S. Court of Federal Claims reviews claims of vaccine-caused injuries. During the first eight years of NVICP a total of 786 contested cases were resolved; this is a tiny fraction of pre-vaccination adverse outcomes, but offers a mechanism to evaluate and compensate any actual immunization injuries.

No medicine is 100% safe; vaccines are among those that have the best balance between immense positive and rare negative effects.

Don't vacillate, vaccinate instead!

Wednesday, March 21st, 2012

Could she have measles?

The Wall Street Journal this morning had an article titled, "Where Could The Next Outbreak Of Measles Be?" A secondary heading on a later page said, "Low Vaccination Rates Trigger Fears," and there was a US map showing problem areas. Boulder, Colorado was one of those hot spots.

The article led me back to the concept of "herd immunity," very well illustrated on a webpage from the National Institute of Allergy and Infectious Diseases. Basically it says we need a relatively high percentage of a given population to be vaccinated (AKA immunized) against a given disease in order to prevent epidemics.

The particular viral disease I'm writing about is measles, sometimes called "red measles" or, technically, rubeola. The National Library of Medicine has an excellent, brief description of this ailment and notes that before widespread vaccination became common, most people had a case of measles before age 20.

Then the MMR vaccine was developed by a Merck scientist in the 1960s. Measles incidence went from being, as a 1954 quote termed it, "as inevitable as death and taxes," to an uncommon to rare disease in developed countries. In the US for the twenty years after the vaccine was licensed, an estimated 52 million overall cases, 17,400 leading to mental retardation and 5,200 deaths were prevented.

In 2000 the WHO estimated that there were still ~45 million cases of measles worldwide yearly causing 800,000 deaths. While mortality in developed countries was ~1/1000, in sub-Saharan Africa, mortality was 10%. In cases with complications, the rate could rise to 20–30%. On average, ~450 children died every day from measles. By 2007 immunizations had cut the yearly global death rate by 75%.

But in 1998 an article in The Lancet had caused a stir that has continued to this day. A British gastroenterologist reported a series of 12 young patients who were referred to his practice with bowel complaints. Their average age was six and 8 of them developed symptoms of autism within a month after they got their MMR injection.

Should I believe what I just read?

Many parents hearing about this report stopped their children's immunizations. This was in spite of numerous much larger studies showing no connection between MMR and autism. In 2005 a Japanese group showed an increase in autism diagnoses in children who got their childhood immunizations after the country's particular MMR vaccine was withdrawn from use because of a suspected side effect of the mumps component. In 2009 a review of multiple large studies was published examining three linkages that had been proposed: MMR and autism, thiomerosal (a mercury-based preservative chemical used in some vaccines, but not in MMR) and autism, multiple vaccinations and autism.

The accumulated data from these large groups in a number of countries showed no association between any of these factors and autism. Finally in 2010 The Lancet published a rather wishy-washy retraction of the Wakefield article.  His license had been revoked by the UK General Medical Council and the British Medical Journal's editorial staff published a much stronger condemnation of Wakefield's work in 2011, calling it fraudulent.

And yet today's WSJ article note parts of the US, especially in the northwest, have relatively poor compliance rates with vaccination guidelines. Parents can opt out because of medical, religious or even philosophical concerns. Low-income kids can receive free immunizations under a federally-funded programs, but one physician interviewed said the parents in his practice who don't want their kids vaccinated are wealthy and well-educated.

We've seen some minor outbreaks in the past few years. If we don't overcome parental misinformation and fears, we may have a major epidemic.