Perspectives on vaccine safety, exemptions, and autism links

Tuesday's Washington Post included a story about religious and other non-medical exemptions to state vaccine requirements. The article, "Faith lets some kids skip shots," examines the increase in personal belief exemptions by parents to forgo vaccination and its implications on disease rates as seen by the medical community. Interviewed for the story were Paul Offit, Saad Omer, and Barbara Loe Fisher.

This piece appears a few weeks after the cover story of Time magazine titled "The Truth about Vaccines." The story detailed the ongoing worries about alleged links between MMR or other vaccines with increases in autism rates and the response of the medical community to these concerns. Of particular note is the reporter's discussion of research using genetics and genomics to understand individual responses to vaccination. The story included a useful diagram (.pdf) tracing the recent increase in measles cases in the U.S., an increase suspected of being linked to trends in exemptions.

The Time cover story was likely motivated -- at least in part -- by the case of Hannah Poling which received significant attention this spring. In March, CDC acknowledged that vaccines Poling had received had exacerbated an underlying genetic condition related to mitochondria (a cellular component) leading to symptoms resembling those of autism. The case has been viewed by proponents of the vaccine-autism link as a 'smoking gun,' but CDC officials and others have noted that Poling's diagnosis and condition are exceptional and do not speak to a more general connection between vaccines and autism. The case was the subject of a commentary in the New England Journal of Medicine last month by Paul Offit that focused on the confusion surrounding many aspects of the decision.

Finally, returning to exemptions and their consequences, the New York Times' Ethicist column -- an often light-hearted Q&A on ethical dilemmas -- featured this question last weekend:

"My daughter’s play group consists of children ranging in age from infancy to 4 years old. One mother revealed that she does not vaccinate her son. After much frank but cordial discussion and opinions from pediatricians — some thought she endangered our vaccinated kids; others did not — she felt pressured to leave the group. Did the group behave ethically?"

Based on pediatricians' opinions that the unvaccinated child did not pose a significant threat to her vaccinated playmates (a view that is not held by all in the medical community), 'The Ethicist' concludes that the other parents were wrong to exclude the unvaccinated child.

From CDC: Zoster recommendations, measles outbreak, post-vaccine fainting, and more

Several items of note have been released by CDC in recent weeks, including:

• "Prevention of Herpes Zoster: Recommendations of the Advisory Committee on Immunization Practices" -- The publication making official the recommendations regarding the use of Merck's zoster vaccine, Zostavax. In short, routine vaccination of all persons age 60 and older is advised, except for those with specific contraindications.

• "Measles--United States, January 1-April 25, 2008" -- A report on the unexpectedly large number of measles cases confirmed in the U.S. in the early months of the 2008. Of the 64 cases, 63 occurred in people who were unvaccinated or were of undocumented vaccination status. The report notes that a large number of the cases occurred in children whose parents had received philosophical exemptions from vaccine requirements.

• "Syncope After Vaccination--United States, January 2005-July 2007" -- The arrival of newly recommended adolescent vaccines has led to an increase in fainting, particularly among 11-18 year old females, CDC reports. One fatality has been confirmed as a result of a head injury caused by a fainting-induced fall. The report reiterates a previous recommendation to observe patients for 15 minutes following vaccination to reduce the risk of falls and injuries caused by fainting.

• NCIRD Annual Report -- The 2008 annual report of the National Center for Immunization and Respiratory Diseases -- the administrative home of most of CDC's vaccination-related activities -- was released last month. Of interest to those interested in the breadth of CDC's immunization activities, it its own words.
  

Updates on measles epidemics in U.S. and worldwide

A few items of note regarding measles outbreaks during the past few years:

• We've written several times about the 2005 measles outbreak in Indiana that sickened 34 (such as here and here). This AP story from late last month confirms what was widely speculated to be the cause of the outbreak: a 17-year old unvaccinated girl who traveled to a Romanian orphanage as part of a church mission trip, according to CDC.

• Farther from home, PLoS Medicine published yesterday a paper with the provocative (but accurate) title: "Unacceptably high mortality related to measles epidemics in Niger, Nigeria, and Chad," looking at mortality rates in three epidemics in 2004 and 2005. Accompanying the paper is an editorial titled "Measles still has a devastating impact on unvaccinated populations." To those close to global vaccination programs, the title will likely seem laughably obvious, but the paper is a noble effort to draw attention to the continued suffering caused by a completely preventable disease.
  

Follow-up: NY Times editorial on '05 measles outbreak

Following up on the report in last week's NEJM about a measles outbreak in Indiana -- the subject of our last post -- today's New York Times includes an editorial that takes a strong stand against parents declining vaccination. Titled "The Measles Vaccine Follies," the editorial points to 'irrational fears of vaccination' as being responsible for the outbreak that sickened 34. Noting that many of those exposed were home schooled, and thus unaffected by school vaccination requirements, the Times ends this way:

"Families that evade vaccination put themselves and their neighbors at risk. All young children, not just those attending school, should be required to get immunized."

(By the way, this is our 100th post and comes -- coincidentally -- on the 5-month anniversary of our launch back in March. Many thanks for your visits to the site; they have made this experiment far more successful than even our most optimistic expectations.)

NEJM on measles in the U.S.

This week's issue of the New England Journal of Medicine includes two pieces that explore the status of measles in the U.S., particularly in relation to a 2005 outbreak in Indiana. That outbreak -- the largest in a decade -- was triggered by the return of a 17-year old unvaccinated girl who traveled to an orphanage in Romania as part of a church group.

One paper is a report tracing the spread of the virus from that individual through everyone she exposed. Titled "Implications of a 2005 Measles Outbreak in Indiana for Sustained Elimination of Measles in the United States" (available free), it concludes, in part:

"Measles was eliminated in the United States through high rates of routine childhood vaccination coverage. The outbreak in Indiana shows that states, localities, and health care organizations need to implement more effective policies to protect persons traveling abroad, home-schooled children, and health care workers against measles and other vaccine-preventable diseases. In addition, to preclude the experience of those countries where vaccine-preventable diseases have become epidemic through the refusal of vaccination, better communication strategies are needed concerning the adverse events associated with vaccines."

The second is a perspective essay by E. Kim Mulholland, M.D., from the London School of Hygiene and Tropical Medicine. Titled "Measles in the United States, 2006," Dr. Mulholland's conclusion is sure to raise the ire of critics of vaccine policy and safety. Putting the blame for outbreaks such as that in Indiana on those alleging vaccine safety issues, Mulholland writes:

"And as long as some groups within a given community respond to spurious claims about the risks of the vaccine by refusing to vaccinate their infants, further outbreaks will occur even in industrialized countries."

"Get wild at a measles party"

Der Spiegel is rarely on the list of news sources we scan for developments in the world of vaccines, but we admit being intrigued upon seeing the headline above. Ironically, the story appears in a section of the site dubbed the "Germany Survival Bible," a traveler's guide to the upcoming World Cup. The story's subhead only adds to the fascination:

"Imagine being invited to a party where the sole purpose is to infect your child with measles. It's actually not all that uncommon in Germany. But then, many in the country are afraid of vaccines."

The premise is that the country's lack of vaccination requirements, national skepticism over ingesting chemicals, and what the story describes as the "widespread German feeling that whatever doesn't kill you makes you stronger" combine to explain the motivation behind the practice. We're by no means experts on German culture or its public health attitudes, but the story sounds eerily similar to the all-anecdote, no-data 'hot new trend' stories that surface from time to time in U.S. publications.

News Roundup -- Measles and Bird Flu

Several items of note that appeared during our brief break from posting necessitated by the Center for Bioethics' 10th Anniversary Symposium, on the legacy of the Terri Schiavo case...

• The New York Times series 'Diseases on the Brink' (which we discussed previously) wrapped up Sunday with an extensive package examining measles eradication efforts worldwide. Of particular note is this graphic illustrating immunization rates by country. It's no surprise that the nations with inadequate measles vaccination levels are nearly all in Sub-Saharan Africa and South Asia, mirroring the trend shared with other vaccinations and most medical interventions.

• Yesterday, the Times also had a provocative 'What If?' piece that asked avian flu experts and government officials about the possibility of administering poultry flu vaccines to humans in a worst-case scenario. Described in the story as 'aghast' at the possibility, NIAID Director Dr. Anthony Fauci is quoted saying, "It's not even on the table." Others interviewed suggest that poultry vaccines might be of some benefit, but they could only be considered for humans in the most catastrophic circumstances. By any estimation, the scientific, production, safety, and ethical issues are so enormous that it's hard to imagine any scenario in which this would actually occur.

• Speaking of avian flu and worst-case scenarios, ABC has quickly assembled a TV movie on the topic, just in time for the May 'sweeps'. "Fatal Contact: Bird Flu in America" will air next Tuesday, May 9 at 8 PM eastern. The ABC press release is available here, as are a number of photos from the film overflowing with actors in biohazard suits. Despite ABC's assurances that the film will contribute to public understanding of the topic, many in the public health and medical communities are wondering whether the film is more likely to scare rather than inform, as this AP story printed in the Philadelphia Inquirer explains.

Encouraging news about worldwide measles vaccination

From ABCNews.com:

"A global immunization drive has cut measles deaths by nearly half during the last six years, the World Health Organization and United Nations Children's Fund said Friday.

Deaths from measles dropped from 871,000 in 1999 to an estimated 454,000 in 2004, according to the UNICEF and WHO report, marking a 48 percent decrease in fatalities suffered from one of the most contagious diseases known."

A tremendous achievement, and a testament to the effectiveness of sound public health interventions and robust vaccination campaigns. Still, the potential exists for even greater victories over measles in the years ahead. Putting these global numbers in context, according to this CDC data, the total number of measles cases (not deaths) in the U.S. in 2005 was a mere 63, thanks to 40 years of vaccination.