Life and Limb: The Price of Not Vaccinating Children

A recent article in USA Today focused some light on the issue of vaccine avoidance and its consequences. Two specific examples in the article included the death of an infant to pertusis and healthy boy who lost his arms and legs as a consequence of the measles. In my opinion, the authors and editors of this publication make a mistake by offering up too much credence to the vaccine naysayers presumably to provide a “balanced report.”  Their arguments should have been subjected to further scrutiny.  Here’s the link, decide for yourself:

http://usat.ly/1lEVlOe

Excerpt:

Recent measles outbreaks in New York, California and Texas are examples of what could happen on a larger scale if vaccination rates dropped, says Anne Schuchat, the CDC’s director of immunizations and respiratory diseases. Officials declared measles, which causes itchy rashes and fevers, eradicated in the United States in 2000. Yet this year, the disease is on track to infect three times as many people as in 2009. That’s because in most cases people who have not been vaccinated are getting infected by others traveling into the United States. Then, Schuchat says, the infected spread it in their communities.

The 189 cases of measles in the U.S. last year is small compared with the 530,000 cases the country used to see on average each year in the 20th century. But, the disease — which started to wane when a vaccine was introduced in 1967 — is one of the most contagious in the world and could quickly go from sporadic nuisance to widespread killer.

Measles kills about once in every 1,000 cases. As cases mount, so does the risk. “We really don’t want a child to die from measles, but it’s almost inevitable,” says Schuchat. “Major resurgences of diseases can sneak up on us.”…

Even so, in some states the anti-vaccine movement, aided by religious and philosophical state exemptions, is growing, says Paul Offit, chief of infectious diseases at Children’s Hospital of Philadelphia. He points to states like Idaho, Illinois, Michigan, Oregon and Vermont — where more than 4.5% of kindergartners last year were unvaccinated for non-medical reasons — as examples of potential hot spots. Such states’ rates are four times the national average and illustrate a trend among select groups.

“People assume this will never happen to them until it happens to them,” Offit says. “It’s a shame that’s the way we have to learn the lesson. There’s a human price for that lesson.”

The most vulnerable are infants who may be too young to be vaccinated, children with compromised immune systems and others who may be unable to be vaccinated for medical reasons, scientists say.

Related blog posts:

Vaccine successes and ambitions

“Designing Tomorrow’s Vaccines” is a fascinating assessment of the success of vaccines as well as a look into the what future vaccines may accomplish (NEJM 2013; 368: 551-60).

First, I like the quote from Thomas Jefferson noted in the article:

“I avail myself of this occasion of rendering you a portion of the tribute of gratitude due to you from the whole human family.  Medicine has never before produced any single improvement of such utility…mankind can never forget that you have lived. Future nations will know by history only that the loathsome small-pox has existed and by you has been extirpated.”  Letter to Edward Jenner (May 14, 1805).

Jefferson’s enthusiasm was not without merit.  “In the 20th century alone, smallpox claimed an estimated 375 million lives.”  Yet, “since 1978, not a single person has died from smallpox.” Unfortunately, at this time, every year “more than 1.5 million children (3 per minute) die from vaccine-preventable diseases.”

Previous success in the U.S: Comparison of the estimated number of cases per year in the 20th century with the number of deaths in the year 2002 from the same diseases:

  • Poliomyelitis: 1.63 million vs 0
  • Diptheria: 17.6 million vs 0
  • Measles: 5.03 million vs 36
  • Pertusis: 1.47 million vs 6632
  • Rubella: 4.77 million vs 20
  • Smallpox: 4.81 million vs 0

Despite these advances, vaccines have “yet to realize their full potential.”  Effective vaccines are needed for malaria, HIV, and tuberculosis.  Vaccines for influenza which rely on 50-year-old technology need to be improved.

So how can this be achieved?

  • Improved knowledge of atomic structure/structural biology has provided new insights into neutralizing antibodies along with specific antibody reactions. This can counter immune evasion by targeting highly conserved regions
  • Millions of gene sequences encoding antibodies within a single individual can be analyzed to improve vaccine design
  • Genomewide sequencing of microbes has improved selection of vaccine targets
  • Improvements in delivery systems, like using viruslike particles or nanoparticles; alternatively, gene-based delivery of vaccines is feasible
  • Recombinant techniques has allowed a shift from egg-based methods

What is not on the horizon  — a vaccine for the half-truths that permeate the discussion.

Related posts:

Why Pertusis is resurgent –it’s not what you think

What are the reasons why pertusis, a vaccine-preventable disease, is epidemic?

According to an editorial by James Cherry (NEJM 2012; 367: 785-87), there are four main reasons.

  • 1) Increased awareness
  • 2) Easier detection with PCR assays
  • 3) Increased use of less potent vaccines, mainly DTaP
  • 4) Possible genetic changes in B pertusis

Useful epidemiology information:

  • 13-20% of adolescents and adults with prolonged cough have B pertusis.
  • Lowest incidence was reported in 1973: 1 per 100,000.
  • In prevaccine era, B pertusis had pattern of epidemics every 2 to 5 years, with peak incidence of 157 per 100,000.
  • In 2010, incidence was 9 per 100,000
  • Neither infection or immunization provides lifelong immunity

His recommendations/conclusions:

  • We need to use the vaccines we have.  This is necessary to avoid the ‘frightening rates of complications and death’ associated with pertusis in infants.
  • Consider starting immunization at an earlier age –1st three doses could be completed by 3 months of age
  • Improved vaccines are needed

Related blog entries:

Protecting the most vulnerable

Hepatitis A vaccine immunity –will it last?

How to stop HBV vertical transmission

Protecting the most vulnerable

Although pediatric gastroenterologists are not on the front lines of the vaccine controversies, we should add our voices to support immunizations.  Some of our immunocompromised patients are among the most vulnerable and rely on herd immunity to lessen their chances of serious infection.  When healthy children and adults do not receive their immunizations, this does not only increase their risk of infections but the risk to others.

A perfect example of this is highlighted in NEJM 2012; 366: 391-92.  In 2010, California reported over 9000 cases of pertusis; of these cases, 89% occurred in infants less than 6 months.  This population is too young to be adequately immunized.  Ten of these infants died.

The author recommends trying to persuade those who are hesitant to proceed with immunizations.  Parents who are opposed based on personal beliefs will not be persuaded.

  • Remove socioeconomic barriers to vaccination
  • Enforce school entry requirements; it should not be easier to opt out of immunizations than to receive them
  • Aggressively address misinformation
  • Learn to use persuasion effectively: http://www.cdc.gov/vaccines/conversations

Additional references:

  • -NEJM 2011; 365: 1108. RV vaccine resulted in 64,000 less hospitalizations in US between 2007-2009.
  • -NEJM 2010; 362: 289, 299, & 358. Rotavirus vaccines lowering death rate in Africa & Mexico.
  • -NEJM 2011; 364: 2283. Rotavirus vaccine: risk of intussception ~1:50,000-1:70,000; thus could cause ~96 cases per year. Vaccine at same time prevented 80,000 hospitalizations & 1300 deaths in Brazil & Mexico.
  • -Gastroenterology 2007; 132: 1287. Two decades of HBV vaccination in Taiwan
  • -NEJM 2007; 16: 1275, 1278, 1281.  Medical evidence refuting Thimersol toxicity; yet many vaccine cases in litigation
  • -Liver Transplant 2008; 14: 1389.  Vaccine policies:  MMR/Varicella can be given as early as 6 months of age. Must give 3-4weeks before Tx. Can give inactivated ~6-12 mo p-OLT. Except for oral polio, good idea for contacts to get all their immunizations.
  • -Inflamm Bowel Dis 2009;15:1410–1416.  Vaccination Strategies for Patients with Inflammatory Bowel Disease on immunomodulators and biologics

Live Virus Vaccines, Generally Contraindicated in Patients Receiving Immune-Suppressive Therapy:

Anthrax vaccine
Intranasal influenza
Measles-mumps-rubella (MMR)
Polio live oral vaccine (OPV)
Rotavirus
Smallpox vaccine
Tuberculosis BCG vaccine
Typhoid live oral vaccine
Varicella
Yellow fever