Not immune: Vaccine-preventable diseases are coming back

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As measles make a comeback in pockets of the United States, a resurgence of vaccine-preventable diseases in Charlottesville in recent years has some local health experts worried that messages about the importance of immunization are not sinking in.

In just the first two months of 2019, the U.S. has seen five outbreaks of measles–a highly infectious disease that killed millions of children each year before a vaccine was introduced in the 1960s. It was declared eradicated in this country in 2000, but has been reintroduced as travelers pick up the disease abroad and then spread it among unvaccinated groups here in the U.S. (In Clark County, Washington, which had more than 50 cases this year, one in four kindergartners were unvaccinated before the outbreak.)

So how vulnerable are we here in Charlottesville?

“We have not had any cases of measles yet at UVA, but I’m concerned,” says Dr. Ina Stephens, a pediatrician and specialist in pediatric infectious diseases at UVA Health System. “There are measles outbreaks all over the U.S.”

Stephens calls non-immunization a “huge issue” globally, particularly in Europe, where there were more than 41,000 cases of measles last year. Much closer to home, she notes, “we are seeing other vaccine-preventable diseases cropping up all over the place here in Charlottesville.” That has included outbreaks of pertussis (whooping cough) that have led to hospitalizations and infant deaths; mumps; severe cases of chicken pox with complications and secondary infections; and several cases of Haemophilus influenzae type B meningitis, which is “almost unheard of,” she says. “We haven’t seen that in 20 years.”

Despite available vaccines, she says, “These diseases are coming back.”

Dr. Ina Stephens

“Vaccine hesitancy”—the delay or refusal of available vaccines—was identified by the World Health Organization as one of the top 10 threats to global health in 2019. In the U.S., increasing numbers of parents have been refusing vaccines for their children, although overall vaccination rates remain high.

A strain of anti-vaccine sentiment has run through Charlottesville’s discourse for years: In 2005, The Hook published a cover story suggesting that thimerosal, once an ingredient in the MMR vaccine, caused autism. Andrew Wakefield, the British doctor who fueled the anti-vaxx movement with a paper also linking the MMR vaccine to autism, was later barred from practicing medicine in the UK, and no other researchers were ever able to replicate his findings. In 2008, the medical journal that published Wakefield’s paper retracted it, and the journal’s editor declared it “utterly false.

Still, in 2016 Wakefield’s anti-vaccine film, Vaxxed, screened in Charlottesville. A member of the Parenting Network of Charlottesville listserve touted the screening, declaring that it revealed a “vast conspiracy at the CDC” and that “millions of people” have been “injured or killed” by vaccines. The forum’s moderators declined to post a response, saying they try to “steer away from contentious subjects.”

Stephens, at UVA, says the spread of misinformation had an effect that can’t be taken back.

“The problem is, this is 10 years in the making of fearing vaccines,” she says. “Once the fear is out there, the fear is out there.”

Marcia Hornberger, the epidemiologist for the Thomas Jefferson Health District, which includes Charlottesville and Albemarle, says the district is always concerned about vaccine-preventable outbreaks, “particularly right now.”

Even in a population with a high vaccination rate, diseases can spread among pockets of unvaccinated people. “The message of not getting vaccinated is prevalent,” Hornberger says,  “And that’s certainly concerning.”

The religious exemption loophole

Like most states, Virginia requires children to be adequately immunized to attend school, even private school. Yet parents can get an exemption simply by signing a waiver claiming that immunization conflicts with their child’s “religious tenets or practices.” Few religions expressly prohibit vaccinations, but it’s an easy loophole for parents who don’t want to vaccinate.

It’s difficult to know how many families use the religious exemption to avoid vaccination. Charlottesville public schools report high rates of vaccination, but there is no data available for the area’s preschools and private schools, and rates can vary widely from school to school. In 2011, a student at the Charlottesville Waldorf School contracted measles, and 40 people who were not adequately vaccinated against the disease were quarantined, although it’s unclear how many of those people were CWS students.

Andrea Bostrom, interim administrator at CWS, said in an email that she had “not heard any chatter” among parents regarding the current measles threat, but declined to share information on how many CWS students are unvaccinated or whether exemption rates have gone up.

One Charlottesville preschool director said a “very small number” of families use the religious exemption, and that it is not a concern. Another said the number of families taking the exemption at her school had recently gone up, to five or six families out of a total of less than three dozen.

“We do worry about this,” she wrote in an email. “Although we have not had recent issues at school, in the past we have seen an occasional issue like chicken pox, which puts some of our pregnant moms in possible danger. We have had both children and parents at the school who have actual immune issues, so children who are not vaccinated can be risking the health of others.”

Years ago, she added, a student came down with whooping cough. “It’s a horrible thing to put a child through, with serious complications,” she wrote. “I think anyone who witnesses something like that would not hesitate to get a vaccination for their child.”

The fact that many parents have not witnessed the reality of these diseases may be part of the problem.

“Parents these days are not scared of these preventable diseases because they’ve never seen them…they don’t understand how big of a threat this is,” Dr. Stephens says.

Whooping cough, for example, can be fatal for infants, who typically aren’t vaccinated before age one. There were 18,975 reportable cases of whooping cough in the U.S in 2017, according to the CDC, and the only way to protect infants is to protect older children. Mumps, meanwhile, can cause sterility in older adolescent males, Stephens adds, noting that there was an outbreak of the disease at UVA last year. 

In her practice, Dr. Stephens encourages parents to talk to her about their concerns. Then she addresses them one by one. “You want the parents to know that you’re willing to work with them and you want to protect their child the same way they want to protect their child,” she says.

A mother herself, she tells patients she never gives a child a vaccine that she’s not willing to give her own children. “I let them know that I’m with them,” she says. “I understand.”

Mythbuster: the facts  on vaccines

Here are some of the questions and concerns Dr. Ina Stephens hears from parents, and her response.

It’s too many vaccines at once! I’m worried it’s more than my child’s immune system can handle

“Each individual vaccine has approximately 10-15 different antigens that the body will make a reaction to, so it will remember it,” Stephens says. A typical virus, like the common cold, carries about 10,000 different antigens. An average child gets about eight or 10 viruses the first year of life—that’s hundreds of thousands of antigens, and nobody’s afraid of that, Stephens says. “[Children’s] bodies are very, very well-equipped to handle making an antibody response to 10-15 antigens.”

Too many needles! I don’t like my child getting so many shots at once.

Many providers will work with parents to space out the shots if that is a concern. “You need to meet the parent where they are,” Stephens says.

Why should we bother? My child is not going to get diphtheria or polio.

Stephens reminds parents of how quickly diseases we thought were eradicated can come back. “I tell them—we didn’t see any measles, and then all of a sudden in 2014 there were 657 reportable cases just in the U.S. alone.” Worldwide, she notes, there were over 173,330 cases of measles in 2017. “That’s crazy, that’s huge.”

How do we know vaccines are safe?

“The public has the right to safe vaccines,” says Stephens, who spent 15 years at the Center for Vaccine Development and Global Health at the University of Maryland. While false information abounds on the internet, parents don’t always have access to the medical research, to actually see the science behind why immunizations are safe and why they are so important. “I also let them know that the vaccine reporting system for adverse events is very active. It’s monitored by the minute, and any adverse effect is looked into.”

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