Tag: measles outbreaks

Why Do We Only Worry About Measles?

Anti-vaccine folks often claim that health officials only worry about measles and measles outbreaks.

They can’t understand why anyone gets concerned by a few measles cases here and there, not understanding that a lot of work goes into containing measles outbreaks and making sure that they don’t grow beyond a few cases.

And health officials don’t just worry about measles. They work to control outbreaks of mumps, pertussis, hepatitis A, and all other diseases too.

Why We Worry About Measles Outbreaks

We do get concerned about measles outbreaks though.

“Whenever measles strikes, it’s more than just an outbreak of a single disease, or an indication that children aren’t receiving their measles shots; it’s also a warning that immunization coverage in general, for all vaccine-preventable diseases, is lower than it should be.

To put it another way: When rates of routine vaccination—children receiving all their shots on schedule, as a preventive measure rather than a reaction to an outbreak—start to fall, the first sign is usually a measles outbreak.”

Seth Berkley on Measles Outbreaks Are a Sign of Bigger Problems

The measles vaccine is among the most effective vaccines we have, so if we are seeing outbreaks, even though measles is very contagious, it means there is a problem.

“A focus on measles surveillance can help detect populations unreached by immunization systems and, by extension, program weaknesses. Measles serves as the ‘canary in the coal mine’ for detecting problems with immunization programs, a characteristic whose importance has recently been highlighted in the context of global health security.”

Orenstein et al on Measles and Rubella Global Strategic Plan 2012–2020 midterm review

In the late 1980s, when we had large outbreaks between 1989 to 1991, with 55,622 cases and 123 deaths, it meant that we weren’t vaccinating enough kids because Federal support for vaccine programs had dropped.

As much as anti-vaccine folks like to try and minimize how serious measles can be, it is easy to see that measles is indeed a serious, life-threatening disease. We had good nutrition, proper sanitation, and modern health care in 1990, and still, a lot of people died with measles. Rates of subacute sclerosing panencephalitis (SSPE), a late complication of measles, went up too, in the years after these outbreaks.

“Measles is a wholly preventable disease, and it was almost eradicated from the country in 1983, when only 1,497 cases were reported. But by 1990, after Federal budget cuts and the end of the Government’s monitoring of immunization programs, more than 30,000 cases of measles and more than 60 deaths were reported.”

Panel Ties Measles Epidemic to Breakdown in Health System

Those outbreaks were fixed, as we improved access to help kids get vaccinated and protected. Unfortunately, the issue with outbreaks today isn’t about access to vaccines, at least not in the developed world. It is about parents intentionally skipping or delaying vaccines.

How do you fix that?

Hopefully with education.

Why You Should Worry About Measles Outbreaks

Did you know that after the measles outbreaks of 1989, we also saw outbreaks of rubella and congenital rubella syndrome?

  • 396 cases of rubella, 4 deaths, and 2 cases of congenital rubella syndrome in 1989
  • 1,125 cases of rubella, 8 deaths, and 32 cases of congenital rubella syndrome in 1990
  • 1,401 cases of rubella, 1 death, and 34 cases of congenital rubella syndrome in 1991

Did you know that because they have overall lower vaccination rates, measles outbreaks in Europe grow far larger, into the tens of thousands of cases, with dozens of deaths?

“We must not tolerate a world in which a child dies from a disease that can be easily prevented with a low-cost vaccine.”

Dr Tedros, WHO Director-General on World Immunization Week 2018

We worry about measles outbreaks, because we don’t want to go back to anti-vaccine folks push us back to pre-vaccine era levels of disease and deaths.

We know what happens when vaccine levels drop too low.

A measles epidemic hit New York City in 1951, as this front page NYTimes article reports.
A measles epidemic hit New York City in 1951, as this NY Times article reports.

We know that vaccines are safe and necessary.

You should know that anti-vaccine propaganda that scares parents away from vaccinating and protecting their kids is rooted in myths and misinformation. They often get away with it because most parents today ahve never seen how devastating measles and other diseases can really be, so they believe stories about the Brady Bunch, instead of the advice of real experts.

You hopefully understand that’s a mistake.

More on Worrying About Measles Outbreaks

How Anti-Vaccine Are You? Take Our Quiz.

It’s easy to be anti-vaccine when you are hiding in the herd. You don’t get vaccinated and you don’t vaccinate your kids, and instead, you simply rely on the fact that everyone else around you is vaccinated to protect you from vaccine-preventable diseases.

Would you vaccinate your high-risk child?
Would you vaccinate your high-risk child? Photo by Janko Ferlic.

Of course, this is a terrible strategy, as we are seeing with the increase in cases of measles and pertussis, etc. It is much better to learn about the importance and safety of vaccines, get fully vaccinated, and stop these outbreaks.

This hasn’t seemed to have deterred most anti-vaccine “experts” yet, as they continue to spout their anti-vaccine myths and misinformation and push their anti-vaccine talking points.

But as they continue to tell you that vaccines don’t work, how about asking what they would do in these ten high-risk situations?

Amazingly, some folks continue to try and justify skipping vaccines and accept the risk of disease, even when that risk is much higher than usual and they could be putting their child’s life in immediate danger!

How will you do with our quiz?

Would you choose to vaccinate in these situations?

1. Baby born to mother with hepatitis B.

You are pregnant and have chronic hepatitis B (positive for both HBsAg and HBeAg). Should your newborn baby get a hepatitis B shot and HBIG?

Background information:
Many anti-vaccine experts tell parents to skip their baby’s hepatitis B shot, saying it is dangerous, not necessary, or doesn’t work (typical anti-vax myths and misinformation).

However, it is well known that:

  • from 10 (HBeAg negative) to 90% (HBeAg positive) of infants who are born to a mother with chronic hepatitis B will become infected
  • 90% of infants who get hepatitis B from their mother at birth develop chronic infections
  • 25% of people with chronic hepatitis B infections die from liver failure and liver cancer
  • use of hepatitis B immune globulin (HBIG) and hepatitis B vaccine series greatly decreases a newborn’s risk of developing a hepatitis B infection (perinatal transmission of hepatitis B), especially if HBIG and the first hepatitis B shot is given within 12 hours of the baby being born

Would your newborn baby get a hepatitis B shot and HBIG?

2. Your child is bitten by a rabid dog.

Your toddler is bitten by a dog that is almost certainly rabid. Several wild animals in the area have been found to be rabid recently and the usual playful and well-mannered dog was acting strangely and died a few hours later. The dog was not vaccinated against rabies and unfortunately, the owners, fearing they would get in trouble, disappeared with the dead dog, so it can’t be quarantined. Should your child get a rabies shot?

Background information:
Although now uncommon in dogs, rabies still occurs in wild animals, including raccoons, skunks, bats, and foxes. These animals can then expose and infect unvaccinated dogs, cats, and ferrets, etc.

To help prevent rabies, which is not usually treatable, in addition to immediately cleaning the wound, people should get human rabies immune globulin (RIG) and rabies vaccine.

The rabies vaccine is given as a series of four doses on the day of exposure to the animal with suspected rabies and then again on days 3, 7, and 14.

Although rare in the United States, at least 1 to 3 people do still die of rabies each year. The rabies vaccine series and rabies immune globulin are preventative, however, without them, rabies is almost always fatal once you develop symptoms. A few people have survived with a new treatment, the Milwaukee protocol, without getting rabies shots, but many more have failed the treatment and have died.

Would your child get a rabies shot? What if he had picked up a rabid bat?

3. Traveling to Romania.

You are traveling to the Romania to see family with your 9-month-old baby. Neither of you have had the measles vaccine. Should you both get vaccinated before making the trip?

Background information:

Over the past few years, over 100 people have died in measles outbreaks across Europe, with many in Romania.

Although the first MMR vaccine is routinely given when children are 12 months old, it is now recommended that infants get vaccinated as early as age six months if they will be traveling out of the country.

Since the endemic spread of measles was stopped in 2000, almost all cases are now linked to unvaccinated travelers, some of whom start very large outbreaks that are hard to contain.

Would you both get vaccinated before making the trip?

4. Tetanus shot.

Your unvaccinated teen gets a very deep puncture wound while doing yard work. A few hours later, your neighbor comes by to give you an update on his wife who has been in the hospital all week. She has been diagnosed with tetanus. She had gotten sick after going yard work in the same area and has been moved to the ICU. Do you get him a tetanus shot?

Background information:
Most children get vaccinated against tetanus when they receive the 4 dose primary DTaP series, the DTaP booster at age 4-6 years, and the Tdap booster at age 11-12 years.

Unlike most other vaccine-preventable diseases, tetanus is not contagious. The spores of tetanus bacteria (Clostridium tetani) are instead found in the soil and in the intestines and feces of many animals, including dogs, cats, and horses, etc.

Although the tetanus spores are common in soil, they need low oxygen conditions to germinate. That’s why you aren’t at risk for tetanus every time your hands get dirty. A puncture wound creates the perfect conditions for tetanus though, especially a deep wound, as it will be hard to clean out the tiny tetanus spores, and there won’t be much oxygen at the inner parts of the wound.

These types of deep wounds that are associated with tetanus infections might including stepping on a nail, getting poked by a splinter or thorn, and animal bites, etc. Keep in mind that some of these things, like a cat bite, might put you at risk because you simply had dirt/tetanus spores on your skin, which get pushed deep into the wound when the cat bites you.

Symptoms of tetanus typically develop after about 8 days and might include classic lockjaw, neck stiffness, trouble swallowing, muscle spasms, and difficulty breathing. Even with treatment, tetanus is fatal in about 11% of people and recovery takes months.

Would you get your teen a tetanus shot?

5. Cocooning to protect baby from pertussis.

Both of your unvaccinated teens go to school with a personal belief vaccine exemption. You are due in a few months and are a little concerned about the new baby because there have been outbreaks of pertussis in the community, especially at their highschool. Should everyone in the family get a Tdap shot?

Background information:
Pertussis, or whooping cough, classically causes a cough that can last for weeks to months.

While often mild in teens and adults, pertussis can be life-threatening in newborns and infants. In fact, it is young children who often develop the classic high-pitched whooping sound as they try to breath after a long coughing fit.

In a recent outbreak of pertussis in California, 10 infants died. Almost all were less than 2 months old.

Since infants aren’t protected until they get at least three doses of a pertussis vaccine, usually at age 6 months, experts recommend a cocooning strategy to protect newborns and young infants from pertussis. With cocooning, all children, teens, and adults who will be around the baby are vaccinated against pertussis (and other vaccine-preventable diseases), so that they can’t catch pertussis and bring it home.

There is even evidence that a pregnancy dose of Tdap can help protect infants even more than waiting until after the baby is born to get a Tdap shot.

Would everyone in your family get a Tdap shot?

6. Nephew is getting chemotherapy.

Your nephew was just diagnosed with leukemia and is going to start chemotherapy. Your kids have never been vaccinated against chicken pox and haven’t had the disease either. Your brother asks that you get them vaccinated, since they are around their cousin very often and he doesn’t want to put him at risk.

Do you get your kids vaccinated with the chicken pox vaccine?

Background information:
Kids with cancer who are getting chemotherapy become very vulnerable to most vaccine-preventable diseases, whether it is measles, flu, or chicken pox.

According to the Immune Deficiency Foundation, “We want to create a ‘protective cocoon’ of immunized persons surrounding patients with primary immunodeficiency diseases so that they have less chance of being exposed to a potentially serious infection like influenza.”

Would your get your kids vaccinated with the chicken pox vaccine?

7. Outbreak of meningococcemia at your kid’s college.

Your child has just gone off to college. There is an outbreak of meningococcemia in her dorm (8 cases already). It is the strain that is included in the Menactra and Menveo vaccines, although she has not been vaccinated. Do you encourage her to get vaccinated?

Background information:
Neisseria meningitidis is a bacteria that can cause bacterial meningitis and sepsis (meningococcemia).

Depending on the type, it can occur either in teens and young adults (serogroups B, C, and Y) or infants (serogroup B).

Although not nearly as common as some other vaccine-preventable diseases, like measles or pertussis, it is one of the more deadly. Meningococcemia is fatal in up to 40% of cases and up to 20% of children and teens who survive a meningococcal infection might have hearing loss, loss of one or more limbs, or neurologic damage.

Meningococcal vaccines are available (Menactra and Menveo) and routinely given to older children and teens to help prevent meningococcal infections (serogroups A, C, Y and W-135). Other vaccines, Bexasero and Trumenba, protect against serogroup B and are recommended for high risk kids and anyone else who wants to decrease their risk of getting Men B disease.

Would you encourage her to get vaccinated against meningococcemia?

8. Cochlear implants.

Your preschooler has just received cochlear implants. Should he get the Prevnar and Pneumovax vaccines?

Background information:
Cochlear implants can put your child at increased risk for bacterial meningitis caused by the Streptococcus pneumoniae bacteria (pneumococcus).

Would he get vaccinated with Prevnar and Pneumovax, as he is no at high risk for pneumococcal disease?

9. Splenectomy

Your child is going to have his spleen removed to prevent complications of hereditary spherocytosis. Should he get the meningococcal and pneumococcal vaccines first?

Background information:
Without a spleen, kids are at risk for many bacterial infections, including severe infections caused by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis bacteria.

In addition to their routine vaccines, kids with asplenia might need Menveo or Menactra, Bexsero or Trumenba (Men B), and Pneumovax 23.

Would your child get these vaccines that are recommended for kids with asplenia?

10. Ebola

Ebola is returning, but this time an experimental vaccine is available.

Background information:
There were nearly 30,000 cases and just over 11,000 deaths during the 2014-16 Ebola outbreak in West Africa.

You are in an area that is seeing an increasing number of Ebola cases and there is still no treatment for this deadly disease. An experimental vaccine is being offered.

Do you get the vaccine?

How Anti-Vaccine Are You?

It’s easy to be anti-vaccine when you are hiding in the herd – seemingly protected by all of the vaccinated people around you.

Would you still delay or skip a vaccine in a high-risk situation?

More on The Anti-Vaccine Quiz

Is Polio Returning to Venezuela?

Breaking News – further tests have found that the person with suspected polio did not have either wild polio or vaccine-derived poliovirus (VDPV). Could it still be polio? (see below).

Polio is on the verge of being eradicated.

In 2017, there have only been 118 cases of polio in the whole world, including 22 cases of wild poliovirus in Afghanistan and Pakistan and 96 cases of vaccine-derived poliovirus (VDPV) in the Democratic Republic of Congo and Syria.

So far this year, there have only been 15 cases of polio in the whole world, including 10 cases of wild poliovirus in Afghanistan and Pakistan and five cases of vaccine-derived poliovirus (VDPV) in the Democratic Republic of Congo and Nigeria.

Is Polio Returning to Venezuela?

Most of us are aware that vaccine-preventable diseases are just a plane ride away.

We see it, or at least read about it, all of the time, as we continue to see outbreaks of measles affecting our communities.

But polio?

Could polio return?

Venezuela has been polio free for nearly 30 years. The last case of a wild poliovirus infection was in March 1989. And yet ,there are now thought to be at least four cases of poliovirus, type 3 in the Delta Amacuro state of north east Venezuela, where they are also seeing cases of diphtheria and measles.

Report of polio in Venezuela

Among the polio cases is a 2-year-old boy who was unvaccinated, an unvaccinated child who lived next to him, and a partially vaccinated child 8-year-old who lived next door.

“It has been reported unofficially that it is polio vaccine virus.”

Venezuelan Society of Public Health Report

But what is the source of the polio vaccine virus?

We supposedly stopped using oral polio vaccines that can shed in January 2016, right?

Actually, we began the switch from trivalent OPV (tOPV) to bivalent OPV (bOPV) in 2016, removing the the type 2 polio virus that is most likely to cause VAPP. Making sure kids get a dose of IPV first also lowers the risk of VAPP. At least it does when kids get vaccinated according to plan.

“Other children from the same community were vaccinated in April 2018 with oral bivalent polio vaccine.”

PAHO on Epidemiological Update Detection of Sabin type 3 vaccine poliovirus in a case of Acute Flaccid Paralysis 

When did the first case appear? Although we are just hearing about it now, his symptoms began in April, right around the time another child received a bivalent oral polio vaccine.

“No additional AFP cases have been identified to date through active search for AFP cases carried out in the community.”

PAHO on Epidemiological Update Detection of Sabin type 3 vaccine poliovirus in a case of Acute Flaccid Paralysis 

Fortunately, in the past month, no further cases have been identified.

Children in Venezuela are supposed to get at least one dose of IPV (inactivated polio vaccine), followed by four doses of bOPV (bivalent oral polio vaccine).
Children in Venezuela are supposed to get at least one dose of IPV (inactivated polio vaccine), followed by four doses of bOPV (bivalent oral polio vaccine).

So what does this all mean?

For one thing, wild polio isn’t returning to Venezuela. And it doesn’t look like we will see a large outbreak of cVDPV, as there are no further cases of AFP in the area.

But it does illustrate that we can easily see a return of vaccine-preventable disease if we don’t keep vaccinating until they are eradicated. Remember, low vaccination coverage is associated with outbreaks of cVDPV. If everyone is vaccinated and protected, then they won’t get polio, whether it is wild type or shed from someone who was vaccinated.

Latest Updates on AFP in Venezuela

While a Sabin type 3 polio virus had been initially isolated from the stool samples of the unvaccinated 34-month-old boy with polio symptoms, further tests have now been completed.

“Tests carried out by the specialized global laboratory for genetic sequencing have ruled out the presence of both wild poliovirus and vaccine-derived poliovirus (VDPV). The latter- VDPV- is a Sabin virus with genetic mutations that give it the ability to produce the disease. There is no risk of spread to the community or outbreaks of polio from this case.”

PAHO

So what does he have?

The possibilities are non-polio AFP, as many viruses and other diseases can cause polio-like symptoms.

So why did he have the Sabin type 3 polio virus in his stool?

It is well known that the oral polio vaccines shed. Even though he was  unvaccinated, he was likely exposed to others in the community who were recently vaccinated, as it is possible to shed the vaccine virus in your stool. The attenuated (weakened) vaccine virus is unlikely to cause symptoms though, unless it develops the mutations found in VDPV strains, which this one didn’t.

“The child is being further evaluated clinically to determine alternative causes of paralysis. The final classification of the case of acute flaccid paralysis [to define whether or not it is associated with the vaccine] will be based on clinical and virological criteria assessed at 60 days after the onset of paralysis.”

PAHO

So despite what folks are reporting, they didn’t say that this case couldn’t be associated with the polio vaccine. We just know that it is isn’t wild polio and the virus doesn’t have the mutations associated with cVDPV strains, which can not only cause polio symptoms, but can also spread from one person to another, causing outbreaks.

Remember, although the attenuated vaccine virus in the oral polio vaccine is unlikely to cause polio symptoms, it sometimes can, in about 1 in 2.7 million doses.

“VAPP at this time can’t be ruled out, of course, as it’s one of the possibilities.”

Communications Officer
Global Polio Eradication Initiative

Could this child have VAPP?

“A VAPP case was most often defined as a case of acute flaccid paralysis (AFP) with residual paralysis (compatible with paralytic poliomyelitis) lasting at least 60 days, and occurring in an OPV recipient between 4 and 40 days after the dose of OPV was administered, or in a person who has had known contact with a vaccine recipient between 7 and 60–75 days after the dose of OPV was administered.”

Platt et al on Vaccine-Associated Paralytic Poliomyelitis: A Review of the Epidemiology and Estimation of the Global Burden

I guess we will find out in a few weeks, as his symptoms started at the end of April.

Still, remember that VAPP is not contagious.

What to Know About Polio Returning to Venezuela

Several cases of a vaccine strain of polio virus have been found in Venezuela, which is linked to low vaccinated levels.

More on Polio Returning to Venezuela

Updated June 17, 2018

Costs of a Measles Outbreak

The endemic spread of measles was eliminated in the United States in 2000, but unfortunately, that hasn’t stopped us from having outbreaks of measles each year.

Since reaching a record low of just 37 cases of measles in 2004, other milestones in the measles timeline we should all know about include that there were:

  • 220 measles cases in 2011, a 15-year record and the highest number of cases since 1996 at least until 2014, when we had at least 667 cases
  • 58 cases in the 2013 New York City measles outbreak and for a short time, the largest outbreak since the endemic spread of measles was eliminated in the United States
  • 382 cases in the 2014 measles outbreak in Ohio and now the largest outbreak since the endemic spread of measles was eliminated in the United States
  • 170 measles cases in the first few months of 2015, including a large outbreak in California that was linked to Disneyland.
  • 188 cases and a measles death in 2015

That’s still far below where we used to be though, especially when you consider that before the first measles vaccine was licensed, there was an average of about 549,000 measles cases and 495 measles deaths in the United States each year.

Containing a Measles Outbreak

Several factors help to limit the measles outbreaks that we continue to see in the United States. Most important is that fact that despite the talk of personal belief vaccine exemptions and vaccine-hesitant parents not getting their kids vaccinated, we still have high population immunity.

In the United States, 90.8% of children get at least one dose of the MMR vaccine by the time they are 35 months old and 91.1% of teens have two doses. While not perfect, that is still far higher than the 81% immunization rates the UK saw from 2002 to 2004, when Andrew Wakefield started the scare about the MMR vaccine. Instead of overall low immunization rates, in the U.S., we have “clusters of intentionally under-vaccinated children.”

It also helps that the measles vaccine is highly effective. One dose of a measles vaccine provides about 95% protection against measles infection. A second, “booster” dose helps to improve the effectiveness of the measles vaccine to over 99%.

To further help limit the spread of measles, there are a lot of immediate control measures that go into effect once a case of measles has been suspected, from initiating contact investigations and identifying the source of the measles infection to offering postexposure prophylaxis or quarantining close contacts.

That’s an awful lot of work.

A 2013 measles outbreak in Texas required 1,122 staff hours and 222 volunteer hours from the local health department to contain.

Costs of a Measles Outbreak

In addition to requiring a lot of work, containing a measles outbreak is expensive.

A study reviewing the impact of 16 outbreaks in the United States in 2011 concluded that “investigating and responding to measles outbreaks imposes a significant economic burden on local and state health institutions. Such impact is compounded by the duration of the outbreak and the number of potentially susceptible contacts.”

We still don’t know what it cost to contain many big outbreaks, like the ones in New York City and Ohio, but we do know that it cost:

  • over $2.3 million to contain the 2017 outbreak in Minnesota – 75 people got measles, 71 were unvaccinated, and more than 500 people were quarantined over a 5 month period
  • up to an estimated $3.91 million (but likely much more) to contain the 2015 outbreaks in California
  • two unrelated cases in Colorado in 2016 cost $49,769 and $18,423, respectively to investigate
  • $50,758.93 to contain an outbreak at a megachurch in Texas
  • $150,000 to contain (13 cases) an outbreak in Cook County, Illinois
  • $223,223 to contain (5 cases, almost all unvaccinated) to contain another outbreak in Clallam County, Washington, an outbreak that was linked to the death of an immunocompromised woman.
  • more than $190,000 of personnel costs in Alameda County, with 6 cases and >700 contacts, it is estimated that over 56 staff spent at least 3,770 hours working to contain the outbreak
  • $5,655 to respond to all of the people who were exposed when a 13-year-old with measles was seen in an ambulatory pediatric clinic in 2013
  • $130,000 to contain a 2011 measles outbreak in Utah
  • $24,569 to contain a 2010 measles outbreak in Kentucky
  • $800,000 to contain (14 cases, all unvaccinated) a 2008 measles outbreak at two hospitals in Tuscon, Arizona
  • $176,980 to contain a 2008 measles outbreak in California
  • $167,685 to contain a 2005 measles outbreak in Indiana – unvaccinated 17-year-old catches measles on church mission trip to Romania, leading to 34 people getting sick, including an under-vaccinated hospital worker who ends up on a ventilator for 6 days
  • $181,679 (state and local health department costs) to contain a 2004 measles outbreak in Iowa triggered by a unvaccinated college student’s trip to India
Ending with 667 cases, 2014 became the worst year for measles in the United States since 1994.
Ending with 667 cases, 2014 became the worst year for measles in the United States since 1994. How much did these outbreaks cost to contain?

It is important to keep in mind that these costs are often only for the direct public health costs to the county health department, including staff hours and the value of volunteer hours, etc. Additional costs that come with a measles outbreak can also include direct medical charges to care for sick ($14,000 to $16,000) and exposed people, direct and indirect costs for quarantined families (up to $775 per child), and outbreak–response costs to schools and hospitals, etc.

We should also consider what happens when our state and local health departments have to divert so much time and resources to deal with these types of vaccine-preventable diseases instead of other public health matters in the community. Do other public health matters take a back seat as they spend a few months responding to a measles outbreak?

There were 220 cases of measles in the United States in 2011. To contain just 107 of those cases in 16 outbreaks, “the corresponding total estimated costs for the public response accrued to local and state public health departments ranged from $2.7 million to $5.3 million US dollars.”

In contrast, it will costs about $77 to $102 to get a dose of the MMR vaccine if you don’t have insurance. So not only do vaccines work, they are also cost effective.

What to Know About the Costs of a Measles Outbreak

Containing a measles outbreak is expensive – far more expensive than simply getting vaccinated and protected.

More on the Costs of a Measles Outbreak

Comparing Lightning Strikes to Measles Deaths

Have you ever heard that your child has more of a chance of getting hit by lightning than getting measles?

Since getting struck by lightning is rare, folks like to use it in comparisons to other things that they also think are low risk when trying to make a point.

There are problems with this type of argument though.

Understanding Risk Perception

In an age when many folks are overly anxious about things, it is important to understand the difference between real and perceived risks. Unfortunately, our biases often lead us to worry about the wrong things, sometimes with tragic consequences.

“No intervention is absolutely risk free. Even the journey to a physician’s office with the intention to receive a vaccination carries the risk of getting injured in an accident. With regards to risks of vaccination per se, one has to distinguish between real and perceived or alleged risks.”

Heininger on A risk–benefit analysis of vaccination

Vaccines have risks, but they are small risks, as we know that vaccines are safe and necessary and the decision to skip or delay your child’s vaccines carries with it a much greater risk.

Comparing Lightning Strikes to Vaccine Preventable Diseases

How common or rare do you think it is to get hit by lightning?

  • odds of being hit by lightning – 1 in 1,171,000 (each year)
  • odds of ever being hit by lightning – 1 in 14,600 (lifetime risk)
  • on average, 26 people die after being struck by lightning each year (since 2007), which is down from a recent historical average of 45 deaths per year (30 year average) and way down from when we used to see 400 lightning strike deaths each year before 1950
  • on average, 252 people are injured after being struck by lightning each year
Actually, just since 2000, at least 5 people have died of measles in Canada.
Actually, just since 2000, at least 6 people have died of measles in Canada.

Although 26 people dying after lightning strikes sounds like way too many to me, especially since one recent death was a 7-year-old boy in Tennessee playing under a tree, with 1 in 1,171,000 odds of getting hit, it sounds like we are pretty safe.

But is it fair to use those odds to justify your decision to keep your kids unvaccinated?

Of course not!

Why is our risk of getting struck by lightning so low?

What happens when we hear thunder or see lightning?

When Thunder Roars, Go Indoors!

What happens when a thunder storm approaches and you are at your kids soccer or baseball game?

“Postpone or suspend activity if a thunderstorm appears imminent before or during an activity or contest (irrespective of whether lightning is seen or thunder heard) until the hazard has passed. Signs of imminent thunderstorm activity are darkening clouds, high winds, and thunder or lightning activity.”

UIL on Lightning Safety

Many ball fields now have lightning detectors to alert officials of nearby storms. And just about everyone has access to weather apps on a smart phone that can alert them to an approaching thunder storm or nearby lightning strikes.

The point is that most of us understand that lightning is dangerous, so we go far out of our away to avoid getting hit. The risk of getting hit by lightning isn’t 1 in 1,171,000 with folks running around outside waving golf clubs in the air during thunder storms or sitting on their roofs under an umbrella watching the storm.

The risk of getting hit by lightning is 1 in 1,171,000 because most of us go inside once we know lightning is nearby.

“Based on the media reports of the fatal incidents, many victims were either headed to safety at the time of the fatal strike or were just steps away from safety. Continued efforts are needed to convince people to get inside a safe place before the lightning threat becomes significant. For many activities, situational awareness and proper planning are essential to safety.”

A Detailed Analysis of Lightning Deaths in the United States from 2006 through 2017

And the same is true with measles and other vaccine-preventable diseases. They aren’t as common as they once were because most of us are vaccinated and protected.

If you skip or delay your child’s vaccines, you will increase the risk that they will get one of these vaccine-preventable diseases. And you will increase the risk that they will get someone else sick.

“I also warn them not to share their fears with their neighbors, because if too many people avoid the MMR, we’ll likely see the diseases increase significantly.”

Dr. Bob Sears in The Vaccine Book

And if enough people don’t get vaccinated, herd immunity fails, and we will see a return of pre-vaccine era levels of disease.

What to Know About Vaccines and Risk Perception

Folks often misuse lightning strikes when they think about risks, not understanding that the risk of getting hit by lightning is low because we take a lot of precautions to avoid getting hit by lightning.

More on Vaccines and Risk Perception

8 Myths About Pediatricians Who Fire Families Who Don’t Vaccinate Their Kids

What actually happens when a pediatrician has a vaccine policy that requires parents to vaccinate their kids or face dismissal from the practice?

Not surprisingly, there are a lot of myths about the controversial issue of pediatricians dismissing families who don’t vaccinate their kids.

1 ) It is a myth that the American Academy of Pediatrics has a policy encouraging pediatricians to dismiss families who don’t vaccinate their kids.

There is no such policy.

Instead, in 2016, about 400 leaders from AAP chapters, committees, councils, and sections voted on a resolution at the 2016 AAP Annual Leadership Forum (ALF) to support pediatricians who dismissed families who didn’t vaccinate their kids.

RESOLVED, that the Academy support, in their policy statements and clinical guidelines about immunizations, pediatricians who decide to discharge patients after a reasonable, finite amount of time working with parents who refuse to immunize their children according to the recommended schedule or who fail to abide by an agreed-upon, recommended catch-up schedule, and be it further RESOLVED, that the Academy continue to support pediatricians who continue to provide health care to children of parents who refuse to immunize their children.

Resolution #80.81SB Supporting Pediatricians Who Discharge Families Who Refuse to Immunize

The resolution also voiced support for pediatricians who didn’t dismiss these patients.

2)  It is a myth that pediatricians dismissing families who don’t vaccinate their kids is a new thing.

Although it is getting a lot more attention now, since that 2016 resolution and a report on Countering Vaccine Hesitancy that soon followed, dismissing or firing families who don’t vaccinate their kids is not new.

A 2005 AAP report, Responding to Parental Refusals of Immunization of Children, discusses the issue.

“In general, pediatricians should avoid discharging patients from their practices solely because a parent refuses to immunize his or her child. However, when a substantial level of distrust develops, significant differences in the philosophy of care emerge, or poor quality of communication persists, the pediatrician may encourage the family to find another physician or practice.”

Responding to Parental Refusals of Immunization of Children

And a study, Dismissing the Family Who Refuses Vaccines, also published in 2005, made it clear that many pediatricians “would discontinue care for families refusing some or all vaccines.”

3)  It is a myth that dismissing families who don’t vaccinate their kids is an evidence based policy.

There is nothing beyond anecdotal evidence that families, when faced with the decision of getting vaccinated or getting dismissed from an office, will choose to get vaccinated.

Again, the latest resolution supporting the idea of dismissing families came because it was voted on and became an official Annual Leadership Forum resolution. In general, only the top 10 ALF resolutions are acted upon urgently by the AAP.

At the time, many pediatricians felt constrained by the previous statements from the AAP that discouraged dismissing these families.

4)  It is a myth that pediatricians dismiss families who don’t vaccinate their kids because they don’t want to be bothered talking about vaccine safety.

Although few pediatricians would want to talk to a parent who is arguing that vaccines are poison, aren’t necessary, and never work, fortunately, most vaccine-hesitant parents don’t actually talk like that. They are usually on the fence or simply scared because of all of the anti-vaccine propaganda they are exposed to and need a little extra time to understand that vaccines are safe and necessary.

A typical vaccine policy gives a parent plenty of time to get their child caught up on vaccines before they might be dismissed from the office.
A typical vaccine policy gives a parent plenty of time to get their child caught up on vaccines before they might be dismissed from the office.

And most pediatricians give them that extra time and do talk to them about their concerns. Despite the perception from some of the headlines you might see, families typically don’t get fired after one visit because they refused one or more vaccines.

5) Pediatricians who don’t dismiss unvaccinated families are supporting the use of alternative vaccine schedules.

While this is certainly true for some providers who actually advertise that they are “vaccine-friendly” and encourage parents to follow a non-standard, parent-selected, delayed protection vaccine schedule, most others understand that there is no evidence to support these alternative schedules and they are simply tolerated until the child can get caught-up with all of his vaccines.

6) It is illegal to dismiss a family who doesn’t want to vaccinate their kids.

While some pediatricians think that it is a bit of an ethical dilemma, the legal issues are very clear.

Physicians can’t simply abandon a patient so that they go without care, but they are typically free to end the physician-patient relationship after giving them formal, written notification, and continuing to provide care (at least in emergency situations) for a reasonable amount of time, giving the family time to find a new physician.

Of course, state and federal civil rights laws protect families from being terminated because of sex, color, creed, race, religion, disability, ethnic origin, national origin, or sexual orientation.

7)  It is a myth that dismissing families who don’t vaccinate their kids will protect those families who do vaccinate and protect their kids.

This is often the main reason that pediatricians use to justify dismissing families who don’t vaccinate their kids. After all, it isn’t fair to the families who come to your office, those who do get vaccinated and protected, if someone who is intentionally not vaccinated gets measles and exposes them all, right?

There seem to be several problems with this idea though:

  • relatively few exposures during outbreaks actually occur in a pediatrician’s office. Looking at most recent measles outbreaks, for example, exposures were more likely to occur while traveling out of the country, in an urgent care center, emergency room, somewhere in the community, or in their own home.
  • infants who get pertussis are usually exposed by a family member
  • while measles is very contagious and the virus can linger in an exam room for hours, other vaccine-preventable diseases are far less contagious. Mumps, for example, typically requires prolonged, close contact, which is why you are unlikely to get mumps at your pediatrician’s office.
  • when dismissed by their pediatrician, there is a concern that families might cluster together in the offices of a vaccine-friendly doctor or holistic pediatrician, making it more likely for outbreaks to erupt in their community if any of them get sick

And that’s the key point. Just because families get dismissed from a pediatrician’s office, it doesn’t mean that they leave the community. Your patients might still see them at daycare, school, at the grocery store, or walking down their street.

Pediatricians who don’t dismiss families who don’t vaccinate their kids often feel that it is better to keep working to help them understand that vaccines are safe and necessary, so that they eventually do get vaccinated and protected.

What about the extra risk in their own offices?

With RSV, strep, cold viruses, and everything else that kids have in the average pediatrician’s office, it is best to take steps to reduce the chances that kids are exposed to all of them. How do you do that? Don’t have a waiting room full of kids that are exposing each other to germs!

8) Most families don’t vaccinate their kids because they don’t trust their pediatrician.

While this is likely true for some, those families who want to see a pediatrician and don’t refuse any other treatments, like their newborn’s vitamin K shot and eye ointment, likely do trust their pediatrician.

Then why don’t they vaccinate and protect their kids?

“In today’s world, smallpox has been eradicated due to a successful vaccination program and vaccines have effectively controlled many other significant causes of morbidity and mortality. Consequently, fear has shifted from many vaccine-preventable diseases to fear of the vaccines.”

Marian Siddiqui et al on the Epidemiology of vaccine hesitancy in the United States

They are likely afraid.

What are they afraid of?

More and more these day, if you ask them, they will likely tell you that they don’t know. It would be much easier if they were afraid of something specific, like the myth that a baby’s immune system is too immature to handle any vaccines, that there are hidden ingredients in vaccines, or that vaccines are somehow associated with autism.

You can answer specific questions about vaccines, but it is harder when they are afraid because they see anecdotal vaccine scare videos or because friends and family members are feeding them misinformation.

“With all the challenges acknowledged, the single most important factor in getting parents to accept vaccines remains the one-on-one contact with an informed, caring, and concerned pediatrician.”

“…nearly half of parents who were initially vaccine hesitant ultimately accepted vaccines after practitioners provided a rationale for vaccine administration.”

“Developing a trusting relationship with parents is key to influencing parental decision-making around vaccines.”

“Pediatricians should keep in mind that many, if not most, vaccine-hesitant parents are not opposed to vaccinating their children; rather, they are seeking guidance about the issues involved, beginning with the complexity of the schedule and the number of vaccines proposed.”

“Because most parents agree to vaccinate their children, this dialogue, which can be started as early as the prenatal interview visit if possible, should be an ongoing process.”

AAP on Countering Vaccine Hesitancy

Whatever their vaccine policy, pediatricians should all work to counter vaccine misinformation and propaganda, so that our families get vaccinated and protected and our communities are safe.

It is also clear that we need new ways to talk about vaccines.

And we definitely new more ways to help everyone learn to think critically, be more skeptical about the things they see and read, and overcome their biases.

What to Know About Pediatricians Who Discharge Families Who Refuse to Immunize Their Kids

Whether they have a vaccine policy that dismisses families who don’t vaccinate their kids or they continue seeing them, pediatricians want to do what is best for their kids.

More on Pediatricians Who Discharge Families Who Refuse to Immunize Their Kids

Do Vaccine Mandates Force Parents to Vaccinate Their Kids?

Listening to some parents talk about new vaccine laws, you would think that pediatricians are going to start kidnapping babies or simply hold them down to force them to get vaccinated and follow the latest immunization schedule.

Is there any truth to that?

Of course not.

The History of Vaccine Mandates

There have been vaccine mandates in the United States since 1827, when Boston became the first city to require all children attending public schools to be vaccinated against smallpox.

Surprisingly though, it took a long time to get vaccine mandates protecting more children. It wasn’t until the 1980-81 school year that there were laws in all 50 states mandating that children required vaccinations before starting school.

This followed continued measles outbreaks in the mid-1970s and studies showing that states with vaccine mandates had much lower rates of measles than states that didn’t. And it likely explains why there were 10 measles deaths in the United States as late as 1980, even though the first measles vaccine was introduced in 1963.

It took even longer for the vaccine mandates to cover kids in all grades and not just those entering school, to cover kids in daycare, and to cover kids in college. And tragically, it didn’t take long for politicians to chip away at those vaccine mandates. Over just a few years, from 1998 to 2000, 15 states added personal belief vaccine exemptions.

Still, even before the addition of personal belief vaccine exemptions and without the abuse of religious exemptions and medical exemptions, vaccine mandates have never equaled forced vaccination.

Even the Vaccination Act of 1853 in the UK, which required everyone to get a small pox vaccine, didn’t actually force them to get vaccinated. It originally levied fines on people until they got the vaccine, but they soon allowed a conscientious exemption to vaccination, which many people took advantage of. Over the years, so many people were claiming conscientious vaccine exemptions in the UK, that in 1946, they repealed their vaccine requirements altogether.

What Is a Vaccine Mandate?

Since a mandate is typically defined as an official order to do something, a vaccine mandate would be an order to get a vaccine. But it is hardly an order to hold down and force a vaccine on someone.

Likewise, state laws that mandate vaccines aren’t forcing kids to get vaccinated. They are typically mandates to get vaccinated before attending daycare, public and private schools, and/or college.

Is your child going to camp this year? They might mandate certain vaccines if kids want to attend.

Do Vaccine Mandates Force Parents to Vaccinate Their Kids?

Do vaccine mandates take away a person’s choice about getting vaccinated?

Anti-vaccine folks go to great lengths to scare you into thinking that someone is going to force you to vaccinate your kids. They aren't...
Anti-vaccine folks go to great lengths to scare you into thinking that someone is going to force you to vaccinate your kids. They aren’t…

Of course not.

Again. We are not talking about forced vaccination.

For example, if you work in a hospital that requires a yearly flu vaccine, you can decide to work somewhere else. Sure, you no longer simply have the choice between getting vaccinated or leaving yourself unprotected and continuing to work at the same job, but you can still decide to skip the vaccine and look for another job.

These are mandates with a choice.

The same is true with vaccine mandates for kids to attend school or daycare. If you choose to skip one or more vaccines for a non-medical reason, then even if you are in a state that doesn’t allow religious or philosophical vaccine exemptions, you won’t be forced to get vaccinated. While it may not be an option you are happy with, homeschooling is an option for those who don’t want to vaccinate their kids.

That is your vaccine choice.

Public education is a benefit of those who comply with mandates or compulsory vaccination laws.

These state immunization laws and vaccine mandates have nothing to do with forced vaccination. They also don’t take away your informed consent, are not against the Nuremberg Code, and are not unconstitutional.

Have kids ever been forced to get vaccinations?

Not routinely, but there have been cases of health officials getting court orders to get kids vaccinated and protected, usually during outbreaks of a vaccine-preventable disease.

In 1991, for example, a judge ruled that parents of unvaccinated children who were members of the Faith Tabernacle Congregation in Pennsylvania had to get a measles vaccine. As a measles outbreak spread through Faith Tabernacle, an associated church, and the rest of the city, there were at least 486 cases of measles in the church, mostly among children, and 6 deaths.

“Parents are free to become martyrs themselves. But it does not follow that they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves.”

Prince v. Massachusetts

In addition to being unvaccinated, these children didn’t get any medical care, as their families instead relied on prayer. Finally, after the order was appealed all the way to the state Supreme Court, only nine children got vaccinated.

When parents disagree about vaccines, a judge might also step in decide that a child be vaccinated over one parent’s objections. A child might also get vaccinated against their parents wishes if they have lost custody for reasons that have nothing to do with the child’s medical issues and so a legal guardian, which might be the state, is making those decisions now.

Still, these are not the usual circumstances we are talking about with state vaccine laws. They are simply laws to get kids vaccinated and protected before they are allowed to attend daycare or school.

What to Know About Vaccine Mandates and Forced Vaccinations

Vaccine mandates do not force parents to vaccinate their kids.

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