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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.

Exemptions

(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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VacciShield: Pixie dust for an imaginary threat

vaccishield

I know by now I shouldn’t be, but I am still amazed by how readily so many people buy into the seemingly endless array of bogus sCAM nostrums. Many are marketed and hawked for the treatment or prevention of diseases that are poorly managed by science-based medicine. There are countless examples of dietary supplements that are purported to effectively treat back and joint pains, depression, anxiety, autism, chronic pain, and chronic fatigue; the list goes on and on. The lure for these treatments is at least understandable and, although frustrated that scientific literacy and rational thought loses out, I empathize with the desire to believe in them. On the other end of the spectrum is the even more ethically corrupt substitution of safe and effective treatments with products that are not. I encountered what I find to be possibly the most frightening and dangerous example of this recently at my practice. A family new to the area called to schedule a routine health-maintenance visit for their 5-year-old daughter. When our nurse reviewed the medical records the mother had faxed over, she noted that the child was unimmunized and explained to her that she would need to begin catch-up vaccinations. The mother matter-of-factly stated that her daughter was actually fully vaccinated with a vaccine alternative. She had received a series of homeopathic vaccines from a naturopath. I am not going to discuss this egregious example of sCAM here, though it was addressed in previous SBM posts.1,2 Instead I’d like to focus on another part of the sCAM spectrum. Here lies a form of sCAM that, in some ways, is even more difficult for me to comprehend. These are products invented, marketed, and sold solely for the treatment or prevention of fictitious diseases or problems that exist only in the realm of fantasy. (more…)

Posted in: Herbs & Supplements, Medical Ethics, Naturopathy, Nutrition, Science and Medicine, Vaccines

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Measles gets a helping hand

In a recent post I shared a bit of my personal, near-death experience with measles during the US epidemic of 1989-1991. As I describe in that post, I contracted a very serious measles infection at the end of medical school, and was highly infectious when I interviewed for a residency position at Seattle Children’s Hospital. Like others my age who received an ineffective, killed measles vaccine between 1963 and 1967, I had not been adequately protected. The MMR vaccine was not yet available, and no boosters were recommended at the time. Unfortunately, though my measles titers (a test of immunity to measles) were checked when I entered medical school, the school’s student health department failed to notice or respond to the results – I was not immune and did not receive a booster dose at that time, as I should have. That mistake was huge, and could have cost me my life. It also caused me to potentially sicken many vulnerable children during my tour of the hospital, as well as others I may have inadvertently exposed during the window of communicability as I walked the streets of Seattle. The Department of Health had to be called to trace all of my steps and attempt to track down and protect any potential contacts.
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Posted in: Epidemiology, Medical Ethics, Politics and Regulation, Public Health, Science and Medicine, Vaccines

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Cashing In On Fear: The Danger of Dr. Sears

I generally know what’s coming next when a parent asks about altering their child’s vaccine schedule: “I was reading Dr. Sears….”

Dr. Sears is a genius. No, not in an Albert Einstein or Pablo Picasso kind of way. He’s more of an Oprah or a Madonna kind of genius. He’s a genius because he has written a book that capitalizes on the vaccine-fearing, anti-establishment mood of the zeitgeist. The book tells parents what they desperately want to hear, and that has made it an overnight success.

Dr. Robert Sears is perhaps one of the best-known pediatricians in the country. The youngest son of Dr. Bill Sears, the prolific parent book writer and creator of AskDrSears.com, Dr. Bob has become the bane of many a pediatrician’s existence. He has contributed to his family dynasty by co-authoring several books, adding content to the family website, and making myriad TV appearances to offer his sage advice. But Dr. Bob is best known for his best-selling The Vaccine Book: Making the Right Decision for your Child. This book, or at least notes from it, now accompanies many confused and concerned parents to the pediatrician’s office. Parents who have been misled by the onslaught of vaccine misinformation and fear-mongering feel comforted and supported by the advice of Dr. Sears, who assures parents that there is a safer, more sensible way to vaccinate. He wants parents to make their own “informed” decisions about whether or how to proceed with vaccinating their children, making sure to let them know that if they do choose to vaccinate, he knows the safest way to do it. And for $13.99 (paperback), he’ll share it with them.

In the final chapter of his book (entitled “What should you do now?”), after reinforcing the common vaccine myths of the day, Dr. Sears presents his readers with “Dr. Bob’s Alternative Vaccine Schedule.” He places this side-by-side with the schedule recommended by the American Academy of Pediatrics and the CDC’s Advisory Committee on Immunization Practices. He then explains why his schedule is a safer choice for parents who chose to vaccinate their children. Without a doubt, the alternative vaccine schedule is among the more damaging aspects of this book. It’s the part that gets brought along to the pediatrician’s office and presented as the the plan going forward for many parents today. But the book is also dangerous in the way in which it validates the pervasive myths that are currently scaring parents into making ill-informed decisions for their children. Dr. Sears discusses these now common parental concerns, but instead of countering them with sound science, he lets them stand on their own as valid. He points out that most doctors are ill-equipped to discuss vaccines with parents, being poorly trained in the science of vaccine risks and benefits. He then claims to be a newly self-taught vaccine expert, a laughable conceit given the degree to which he misunderstands the science he purports to have read, and in the way he downplays the true dangers of the vaccine-preventable diseases he discusses in his book. He then provides parents with what he views as rational alternatives to the recommended vaccination schedule, a schedule designed by the country’s true authorities on vaccinology, childhood infectious disease, and epidemiology.

So what does Dr. Sears have to say, exactly, about the risks of vaccines, and just how out of touch is he with medical science and epidemiology? (more…)

Posted in: Book & movie reviews, Public Health, Science and Medicine, Vaccines

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Georgia on my mind

Scales

My inaugural post was about vaccines, and I promised that I wouldn’t write exclusively on this topic. But something rotten is brewing in the state of Georgia and this story is just too important to ignore.

The first successful challenge to the National Childhood Vaccine Injury Compensation Act (NCVICA) has taken place in Georgia, and we all should be just a little bit worried. In Ferrari v. American Home Products Corp., the plaintiffs, Marcello and Carolyn Ferrari of Atlanta, have sued American Home Products Corp. (otherwise known as Wyeth) and the co-defendant GlaxoSmithKline, claiming that the vaccine preservative thimerosal led to their son’s autism. The consequences of this ruling could effect the health of the entire nation. To understand why, we need to delve a bit into what the NCVICA is exactly, and why it was created in the first place.
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Posted in: Politics and Regulation, Public Health, Science and Medicine, Vaccines

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Where’s the outrage?

I thank everyone for my warm welcome to the SBM community. Although vaccine myth is of particular interest to me, I promise that my posts wont all be vaccine related. There is, unfortunately, much to discuss. In fact I had a difficult time deciding which vaccine-related issue to write about for my inaugural post. In the end I came up with more of an opinion piece, but it’s an issue worth airing. Things in anti-vaccine land may be reaching a dangerous turning point.


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Posted in: Public Health, Science and Medicine, Vaccines

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