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Hot-Zone Schools and Children at Risk: Shedding light on outbreak-prone schools

Hot zones

PEDIATRICS Volume 135, number 2, February 2015

The subject of parental vaccine refusal and the impact that has on disease outbreaks has been covered many times on SBM and elsewhere. I apologize to our readers who are growing tired of the subject, but there is perhaps no subject more deserving of focus and repetition. There’s also an important angle to the discussion that I’ve written on previously and which deserves more attention, and that is the importance of the pro-vaccine parent voice, and the need for that voice to be heard.

It never ceases to amaze me how few of the parents I know think about the risk to their own children from vaccine-exempt children in their schools and communities. Even parents who do think about this rarely seem concerned enough to speak up or even discuss it with others, let alone become active in doing something about it. With the rise in vaccine-preventable disease outbreaks, including the current high-profile Disneyland measles outbreak, and the ongoing pertussis epidemic in California, the tide seems at least to be turning slightly. The dramatic impact that vaccine refusal and the resultant decline in herd-immunity can have on a community is now penetrating the public consciousness. My hope is that parental awareness and outrage grow regarding the flagrant disregard of science, common sense, and citizenship exhibited by those parents who refuse to properly vaccinate their children. My hope is that the culture of tolerance of this intolerable anti-science threat begins to turn, and that it is no longer seen as acceptable for some parents to put the safety of others at risk.

Which brings me to the focus of this post.

My wife and I recently went through the process of deciding where to send our daughter to school. We weighed the pros and cons of several schools, taking into consideration curricular philosophies, student-teacher ratios and facilities, among other things. What we didn’t compare between these schools–and couldn’t in the Commonwealth of Massachusetts–was the number of her classmates that be appropriately vaccinated, and how many parents would be avoiding the vaccine requirements by claiming so-called “religious” exemptions. We didn’t consider or even have access to the information that would tell us the strength of the schools’ protective shield of community immunity, and therefore how protected our daughter would be from contracting dangerous, vaccine-preventable diseases. In Massachusetts, as in most states, information about school vaccination and vaccine exemption rates was not at the time publicly available. Fortunately, Massachusetts has just changed course, and is now publishing these data, though with some very significant exceptions which I will discuss below.

Probably more than any other single issue, parents are concerned about their child’s safety and the safety of their environment, whether it’s the food they eat, the air they breathe, or the cars in which they are driven. Yet when choosing where to send their child to school, the very serious and very real issue of how protected they will be by the shield of community immunity is not even on the radar for most parents. The few states that publish this information (California, Oregon, Vermont, and Washington,) have done so after experiencing dramatic increases in parental vaccine hesitancy. These states also have been at the forefront of tightening the laws that mandate school vaccinations. Wider availability of this information would not only provide parents with valuable knowledge about the potential safety of their children; it would jump-start a national conversation about why this is such an important issue to begin with.

Overall, the United States does an excellent job vaccinating children against a wide array of devastating diseases that were once common causes of childhood illness, disability, and death. The nationwide immunization rate for the key preschool vaccines has held relatively steady near the target rate of 90 percent. This number is misleading, however, as it hides vast regional differences in vaccination rates. Fueled by the rapid spread of vaccine misinformation and the increasing belief in a host of vaccine myths, a growing number of parents are rejecting the recommendations of science-based medicine, choosing to alter the recommended vaccine schedule or skip some or all vaccines completely. This rise in parental vaccine refusal and hesitancy has produced regional “hot zones” of under-immunization, placing all children at risk and leading to outbreaks of previously contained childhood disease across the country. A high community vaccination rate (also called “herd immunity”) is necessary to prevent disease outbreaks. For most diseases the herd immunity threshold is around 90%. That means when community vaccination rates fall below this threshold, outbreaks are likely to occur. In this case, the most vulnerable in our communities are the ones most likely to suffer; those too young to be vaccinated, those who cannot be vaccinated due to health reasons, and those for whom the vaccines do not work. It is clear that the lower the regional vaccination rate, the more likely that region will be source of a vaccine-preventable outbreak.

One stark example of the importance of herd-immunity is demonstrated by comparing two measles outbreaks that occurred in 2003, one in the Marshall Islands, and the other in Mexico. In the Marshall Islands, with a population of only 53,000, the immunization rate for measles was less than 90%. There were a confirmed 826 cases, 100 hospitalizations, and 3 deaths for a case rate of 1.6%. In Mexico, with a population of over 100 million (nearly 2000 times the population of the Marshal Islands), the immunization rate exceeded 95%. Because of this high coverage rate, there were only 41 documented cases for a case rate of 0.00004%. In both outbreaks, most cases were in infants too young to be vaccinated or older children who had not been vaccinated.

2003 Marshall Islands

  • Pop 53,000
  • Immunization rate <75%
  • 826 cases, 100 hospitalized
  • Case rate = 1.6%
  • 3 deaths
  • Most cases in infants too young for vaccine, and older unvaccinated

2003 Mexico

  • Pop > 100 million
  • Immunization rate > 95%
  • 41 cases
  • Case rate = 0.00004%
  • Most in infants too young for vaccine

But we need not travel abroad to find examples of the danger of low vaccination rates. Unfortunately, we now have ample evidence documenting the clustering of vaccine-preventable disease outbreaks in regions with increased rates of vaccine exemption.


(Adapted from © 2014 Institute for Vaccine Safety)

With the exceptions of Mississippi and West Virginia, every state allows a parent to claim a non-medical vaccine exemption for their child. Since valid medical contraindications to vaccination are rare, the rate of medical exemptions is low and has remained stable over time at around 0.5%. However, religious exemptions are allowed in 48 states and 18 states allow so-called personal belief exemptions (PBE). Of course, a religious exemption is a personal belief exemption, and the fact that there exists this distinction is ludicrous and likely unconstitutional as well, since it discriminates against atheists (hence the PBE in some states). On the other hand, there really is no large “main stream” religion that has an official anti-vaccine stance, except perhaps for Christian Science (there is no official anti-vaccine statement, though they traditionally prefer prayer over many medical interventions) and maybe the Dutch Reformed Church (it isn’t really clear). And then there are many small Christian sects that have shunned vaccination, sometimes with grave consequences. But this is really beside the point; it is absurd to allow religious doctrine rather than science to dictate public health policy. Unfortunately, it is shamefully easy for  a parent to vaccine-exempt their child. Some states, like Michigan and California, have made it slightly more difficult for parents to take the steps necessary for claiming an exemption, resulting in a drop in exemption requests in some cases. But loopholes in these laws still make it quite easy for parents to avoid vaccinating their children.

As discussed previously, the exemption rate for the U.S. as a whole has remained relatively stable at 1.5 percent. But there are hot zones of parental vaccine refusal where rates are much higher. In my state of Massachusetts, high exemption rate counties include Berkshire (3.2%), Hampshire (4.2%), Cape Cod (4.5%), and Franklin (6%) counties. But this data is just too granular to see the even more dangerous hot-zones of under-vaccination. To get a better, finer picture of where disease outbreaks are most likely to occur, we need school-level data. We need to see the schools harboring the largest percentage of under-vaccinated children.

After working with officials at the Massachusetts Department of Health, Massachusetts has finally agreed to join California and several other states by making these data available to the public on its website.

For the reasons discussed above, the public availability of this information is crucial to our efforts to push back against the dangers of vaccine refusal. Unfortunately, the Massachusetts data is missing key elements critical to this effort. While I applaud the MDPH for its work on this important project, they have been constrained by their own internal data release standards prohibiting the release of data for schools with fewer than 30 reported kindergarten students. (see MDPH Confidentiality Procedures, Procedure 7). This includes the smaller, private schools that are so often the choice of the more affluent, educated, and “well-informed” parents most likely to hold anti-science, anti-vaccine beliefs, and to request vaccine exemptions for their children. The rationale for this policy is related to the fact that, with schools of this size, it becomes more difficult to protect the identities of children who may be vaccine-exempt. In other words in a class of 20 children, it is easier to guess which children may be claiming exemptions. I find this silly, and beside the point. Individual children would not be identified. What this policy does do is deprive parents of important information about the safety of their child’s environment. Honest, fair transparency would allow discussions to take place based on real-life, school-specific risk, and pressure could be placed on those parents who chose to hide in the herd. If every small, private school in my region can be declared “nut-free”, despite little evidence that this drastic policy is necessary to protect nut-allergic children, then surely at least revealing vaccination rates should be acceptable. But, of course, that is not sufficient. What we need is a complete reassessment of our priorities. It is time to eliminate all non-medical vaccine exemptions. It is time we stop pretending that the dangerous practice of not immunizing ones child is a choice worthy of respect and protection. In the meantime, some states are at least making it a bit more difficult for parents to exempt their children. In California, where the exemption rate has doubled since 2007, parents must meet with a provider to discuss the risks of their decision, and provide proof of that encounter as well as a written statement from them. In Michigan, exempting parents must meet with a local health worker to hear about the risks of underimmunization and sign a state form taking responsibility for these risks. A similar law has recently been enacted in Oregon.

As the data now stand, most Massachusetts parents have the information they need to determine if their child’s school is more or less likely to be the epicenter of a vaccine-preventable disease outbreak. But parents who send their children to the smaller private schools most likely to harbor unvaccinated children, are still in the dark.

The Massachusetts DPH has assured me that they will be taking a hard look at their data release policies, with the hope that they can be revised to allow inclusion of smaller schools, such as in California where data is released for schools with kindergartens larger than 10 students in size. In that case, we may soon have a true map of my state’s potential hot-zones for vaccine-preventable disease outbreaks. And parents can begin to have the conversations, and arguments, that need to be had. 

Posted in: Epidemiology, Legal, Public Health, Science and Medicine, Vaccines

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Lies, fraud, conflicts of interest, and bogus science: The real Dr. Oz effect



I thought I’d written my final post on the Dr. Oz-fueled green coffee bean extract (GCBE) diet supplement fad. But now there’s another appalling chapter, one that documents just how much contempt The Dr. Oz Show seems to show for its audience, and how little Dr. Oz seems to care about providing advice based on good science. This week it was revealed that the “naturopath” that Dr. Oz originally featured in his GCBE segment, Lindsey Duncan, didn’t disclose a direct conflict of interest when he spoke. After inaccurately describing the supplement’s effectiveness, he directed consumers, using keywords, to web sites that he owned or operated. The infamous “Dr. Oz Effect” worked, with Duncan selling $50 million in GCBE supplements in the following months and years. This week it was announced that Duncan and his companies have been fined $9 million by the Federal Trade Commission. The documentation released by the FTC [PDF] gives remarkable insight into how a scam to make millions was launched, and how the Dr. Oz Show is a platform for the routine promotion of dubious “experts” and worthless supplements. (more…)

Posted in: Health Fraud, Herbs & Supplements, Naturopathy

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Treating Migraines

I am a headache specialist and so I receive many questions, through SBM, NeuroLogica or listeners of the Skeptic’s Guide to the Universe, about how to best treat headaches, or about a specific, often unusual, treatment. Migraines and severe headaches are very common. According to the latest statistics:

14.2% of US adults 18 or older reported having migraine or severe headache in the previous 3 months in the 2012 NHIS. The overall age-adjusted 3-month prevalence of migraine in females was 19.1% and in males 9.0%, but varied substantially depending on age. The prevalence of migraine was highest in females 18-44, where the 3-month prevalence of migraine or severe headache was 23.5%.

That means about 28 million Americans suffer from migraines. Percentages do vary from continent to continent, but not dramatically. Migraine, therefore, is a huge burden. Headaches can be debilitating when severe, and so also are a major source of lost productivity.

This will be a two-part series reviewing some of the options for treating migraines, focusing on science-based treatments in part I, and non-science-based treatments in part II. None of this is intended to give specific medical advice for any individual. If you have severe headaches you should consult your physician. I will simply be reviewing the evidence for various options, focusing on migraine specifically.

Caffeine, a common trigger for migraines and headaches

Caffeine, a common trigger for migraines and headaches


Posted in: Neuroscience/Mental Health

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Another Misguided Cancer Testimonial

An economic analyst, Mike “Mish” Shedlock, wrote a blog post to describe how he beat prostate cancer. When laymen and patients write about cancer, they are likely to get some things wrong. Mish’s story is full of typical misunderstandings and misinterpretations.

He interpreted his experience in his own way and did his own research into the medical literature, something he was not qualified to do. Prostate cancer is a very complex subject, and understanding the implications of published studies for treating patients can be difficult even for experts. In typical Dunning-Kruger fashion, he rejected the advice of his doctors, thinking he could do better.

Posted in: Cancer, Herbs & Supplements

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An aboriginal girl dies of leukemia: Parental “rights” versus the right of a child to medical care


One topic that keeps recurring and obligating me to write about it consists of critically analyzing stories of children with cancer whose parents, either on their own or at the behest of their child, stop or refuse chemotherapy or other treatment. It is, sadly, a topic that I’ve been discussing for nearly a decade now, starting first on my not-so-super-secret other blog and continuing both there and here. Indeed, the first post I wrote about this problem was in November 2005, a fact that depressed me when I went back through the archives to find it because so little has changed since that time.

I was painfully reminded of this last week when stories started circulating in the media about the death of Makayla Sault, an Ojibwe girl and member of the New Credit First Nation in Ontario:

The entire community of New Credit is in mourning today, following the news of the passing of 11 year old Makayla Sault.

The child suffered a stroke on Sunday morning and was unable to recover. Friends and family from across the province travelled to New Credit First Nation today to offer condolences, share tears and pay their respects.


Posted in: Cancer, Public Health, Religion, Science and the Media

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Upcoming Toronto talk: Complementary and Alternative Medicine: A Business Ethics Perspective

TRSM logo

I’ll be joining Professor Chris MacDonald on January 28 for a discussion about the ethics of selling complementary and alternative medicine:

Is it ethical to market complementary and alternative medicines? Complementary and alternative medicines (CAM) are medical products and services outside the mainstream of medical practice. But they are not just medicines (or supposed medicines) offered and provided for the prevention and treatment of illness. They are also products and services – things offered for sale in the marketplace. Most discussion of the ethics of CAM has focused on bioethical issues – issues having to do with therapeutic value, and the relationship between patients and those purveyors of CAM. This presentation — by a philosopher and a pharmacist — aims instead to consider CAM from the perspective of commercial ethics. That is, we consider the ethics not of prescribing or administering CAM (activities most closely associated with health professionals) but the ethics of selling CAM.

Admission is free. Space is limited. Register here.

WHAT: Complementary & Alternative Medicine: A Business Ethics Perspective

DATE: January 28, 2015

TIME: 3:00 p.m. – 4:30 p.m.

WHERE: Ted Rogers School of Management, Ryerson University, 55 Dundas Street West, Toronto.


UPDATE (January 29, 2015): The talk in its entirety is now online.


Posted in: Announcements

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Gut Check

Lactobacillus acidophilus

Some apparently rather useless Lactobacillus acidophilus

I always cringe when I see an acupuncture headline with ‘needle’ or ‘point’ in the title. Can’t the writer avoid the clichéd pun? I had an editor who commented that the titles of my essays are often obtuse. Probably true. In going back over my essays on SBM I often can’t tell from the title what I have written about until I read the article. It is a fine line between (what I think) is a clever title and obscurity. So gut check it is.

Time flies when you are having fun. I wrote about probiotics back in 2009.

My conclusion at the time:

Probiotics are useful for the prevention of antibiotic-associated diarrhea. Probiotics may be helpful in preventing other overgrowth syndromes or diseases associated, and perhaps with perturbations of the gut microbial flora such as IBS and colic.

Probiotics are foreign bacteria that are not a normal part of your GI tract; they do not enhance your immune system and, in normal people do not promote the nebulous bowel health.

If you are a normal human, with a normal diet, save your money. Probiotics have nothing to offer but an increased cost.

Medicine is not static and there have been interesting advances in the understanding of the human microbiome in health and disease since 2009, so for SBM and my own medical understanding, I thought it would be a good opportunity to review the topic. Although with over 12,000 references on the PubMeds, I will only touch on a smattering of the papers. My ID attending in medical school always referred to reading the medical literature as drinking from a fire hose. Indeed. (more…)

Posted in: Herbs & Supplements

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Are skin-lightening glutathione injections safe and effective?

A Toronto naturopath’s advertisements were recently criticized on social media for insensitivity and racism:

Glutathione Advertisement TTC Jean-Jacqques Dugoua

Picture used with permission of @emilyknits

Naturopath Jean-Jacqques Dugoua sells glutathione injections, claiming it will give “brighter, lighter and glowing skin”. His URL, seems to imply that lighter skin is more natural, and he claims the following:

After over 3 years of treating patients for skin concerns, Dr. JJ has developed the Skin Brightening IV, which includes glutathione, vitamin C and other vitamins/minerals. Not only is this treatment effective for most people, it is also safe. The Skin Brightening IV glutathione is a good alternative to skin bleaching creams, which can damage, scar, inflame, discolour or irritate the skin, or microderm abrasion, which is painful and may also irritate the skin and sometimes worsen hyper-pigmentation.

This safe and natural treatment involves principally the use of intravenous (IV) vitamins (excluding vitamin A), minerals and amino acids, including glutathione. All ingredients are regulated by Health Canada and obtained from pharmacies or pharmaceutical companies in Canada or the United States. The treatment is performed in compliance with licensure in Ontario.


Posted in: Science and Medicine

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Unfalsifiable Beliefs


As we search for a logo for SBM or the SfSBM, Mark Crislip has been a strong advocate of using an image of Sisyphus, endlessly pushing a boulder up a hill only to have it roll back down again. It’s a bit too self-defeating to be enthusiastic about that suggestion, but it does reflect a common feeling among all of us here at SBM – promoting science can be a frustrating endeavor.

Our frustration reflects a broader phenomenon, that it is difficult to persuade people with facts and logic alone. People tend to prefer narrative, ideology, and emotion to facts. The high degree of scientific illiteracy in the culture presents another barrier.

In recent years psychologists have demonstrated experimentally what we have come to understand through personal experience, that people engage in a host of cognitive defense mechanisms to protect their beliefs from the facts. We jealously guard our world view and are endlessly creative in shielding it from refutation.

A recent series of experiments published by Friesen, Campbell, and Kay in the Journal of Personality and Social Psychology demonstrates that one strategy commonly used to protect our beliefs is to render them unfalsifiable, or at least incorporate unfalsifiable elements. (more…)

Posted in: Critical Thinking

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Shedding Light on Unreasonable Decisions


One of the biggest frustrations for a doctor is when a patient refuses to take science-based medical advice. We would like to believe that giving a patient accurate information will lead him to make good decisions that will improve his health or save his life. But that’s not how it works. Patients reject life-saving surgery and chemotherapy, patients on essential medications are non-compliant, parents reject vaccines for their children…what are these people thinking? Why would anyone in their right mind knowingly reject a treatment that has been proven to increase their chances for survival and health? What could their reasons possibly be?

This ties into a subject we have debated over and over: why do people choose alternative medicine? Many reasons have been suggested: cost and accessibility, the need for control, dissatisfaction with mainstream medicine, the peer pressure of a popular fad, “belonging” to a group of like-minded people, a need for answers, autonomy, health freedom, ideology, rebellion against authority, a need for hope even if it is false hope, giving more importance to stories than to studies, the post hoc ergo propter hoc fallacy, scientific illiteracy, misinformation, superstition, magical thinking…the list goes on. Studies have been done, but we can’t be sure the reasons people give to researchers are the real reasons. There is a problem with the search for reasons: these decisions are not made on the basis of reason. Physician Lisa Rosenbaum has written a beautiful essay in The New England Journal of Medicine entitled “Beyond Belief — How People Feel about Taking Medications for Heart Disease“, that sheds a penetrating light on what is really going on. It made me think of the subject in a whole new way. (more…)

Posted in: Critical Thinking

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