Tag: MMR

About Those Vaccine Strains in Measles Outbreaks…

A lot happens to control and contain a measles outbreak these days.

For one thing, you have to confirm that everyone with measles symptoms actually has measles. If you miss anyone, because measles is so contagious, then they could expose other people and the outbreak will keep getting bigger.

How do they confirm who has measles and who doesn’t?

While you could just make a clinical diagnosis, simply relying on the person’s history and pattern of symptoms, typically everyone just gets tested.

About Those Vaccine Strains in Measles Outbreaks…

What kind of testing?

“Laboratory confirmation is essential for all sporadic measles cases and all outbreaks. Detection of measles-specific IgM antibody and measles RNA by real-time polymerase chain reaction (RT-PCR) are the most common methods for confirming measles infection. Healthcare providers should obtain both a serum sample and a throat swab (or nasopharyngeal swab) from patients suspected to have measles at first contact with them. Urine samples may also contain virus, and when feasible to do so, collecting both respiratory and urine samples can increase the likelihood of detecting measles virus.”
Measles For Healthcare Professionals

It depends, but often a throat swab or a throat swab and urine are collected for PCR testing, especially if it has been 7 or fewer days since the patient came down with their rash.

If it has been longer than 7 days, then testing using urine and blood specimens can be performed.

“Molecular analysis can also be conducted to determine the genotype of the measles virus. Genotyping is used to map the transmission pathways of measles viruses. The genetic data can help to link or unlink cases and can suggest a source for imported cases. Genotyping is the only way to distinguish between wild-type measles virus infection and a rash caused by a recent measles vaccination.”
Measles For Healthcare Professionals

Because many people get vaccinated during an outbreak and a rash and fever is a side effect of the MMR vaccine, testing becomes very important in those who were recently vaccinated.

Statistics from the 2015 Disneyland measles outbreak... — Statistics from the 2015 Disneyland measles outbreak. Anti-vaccine folks, this slide doesn’t mean what you think it means.

After getting vaccinated, testing helps confirm that someone has vaccine strain measles and not wild type, a vaccine reaction, and don’t actually have measles.

“Here, we describe a real-time reverse transcription-PCR (RT-PCR) method that detects the vaccine genotype (MeVA RT-quantitative PCR [RT-qPCR]) and that can provide rapid discrimination between wild-type-virus infections and vaccine reactions.”
Roy et al on Rapid Identification of Measles Virus Vaccine Genotype by Real-Time PCR

An no, the vaccine reaction is not that they developed measles! They developed a rash and/or fever, a common side effect of the MMR vaccine.

“During outbreaks, measles vaccine is administered to help control the outbreak, and in these situations, vaccine reactions may be mistakenly classified as measles cases.”
CDC on Genetic Analysis of Measles Viruses

So the reports that you might have seen that 31 people in the California measles outbreak had a vaccine strain of measles aren’t true. There were at least 31 people who were recently vaccinated during the outbreak and had a rash and/or fever, and they tested positive for the vaccine strain, proving that they weren’t actually part of the outbreak. None of them actually had measles though.

Has anyone ever gotten the measles after being vaccinated?

“Vaccine‐associated measles is a possible, but extremely rare event.”
Sood et al on Vaccine‐associated measles in an immunocompetent child

Yes, there are a few case reports.

Very rare case reports.

Who's to blame for low immunization rates and continuing outbreaks? — Who’s to blame for low immunization rates and continuing outbreaks?

We know who’s responsible for the rise in measles outbreaks and no, it ain’t folks who have recently been vaccinated. Vaccines are safe and necessary.

Get vaccinated. Stop the outbreaks.

More Measles Hysteria From Bob Sears

Most folks remember Dr. Bob’s response to the measles outbreak in his home town.

He told folks DON’T PANIC!!!!

More Measles Hysteria From Bob Sears

That was nearly four years ago, during the Disneyland measles outbreak.

So what’s he saying now?

From panic to hysteria - Dr. Bob on the measles outbreaks.

He’s moved from panic (a sudden overpowering fright) to hysteria (behavior exhibiting overwhelming or unmanageable fear or emotional excess), but is still pushing his usual talking points.

He has changed the way he is talking about measles deaths though.

Dr. Bob Sears actually reassured parents that measles wasn't deadly in developed countries, neglecting to mention the dozens of people who have died in outbreaks in Europe - another well-nourished population with lower vaccination rates than the U.S. — Dr. Bob Sears actually reassured parents that measles wasn’t deadly in developed countries, neglecting to mention the dozens of people who have died in outbreaks in Europe – another well-nourished population with lower vaccination rates than the U.S.

Remember how he used to say that measles wasn’t deadly and that no one had died of measles in a long time? Now, instead of acknowledging that a woman got caught up in the 2015 outbreaks in Washington and died, he has shifted to saying that there hasn’t been a pediatric death in a long time.

Either way, it is important to understand something he leaves out. There are few deaths from measles these days because most folks are vaccinated!

When did Dr. Bob’s book about vaccines come out? The one with the alternative vaccine schedule?

Whatever his motivation, let’s take a look at what Dr. Bob is saying about measles…

“Measles hysteria is everywhere. And it’s clear the hysteria is a result of media fear around this disease, a disease every child used to get (and handle virtually without complication) not that long ago.”
Dr. Bob Sears

Not that long ago?

I’ve been a pediatrician for 22 years and I have never seen a child with measles. Neither did I have measles, as I was fortunate enough to grow up in the post-vaccine era for measles – a vaccine that has been available for since the 1960s.

And while every child did indeed once get measles, in the pre-vaccine era, not all handled it without complications, which is why measles was called the harmless killer.

Anti-vaccine folks try to hide the risks of measles in mortality rates, but the reality of it is that about 500 people died each year up until the early 1960s when the first measles vaccine was developed.

And I guess that wasn’t that long ago, after all, we had good hygiene and sanitation and healthcare at the time, and yet, a lot of people still died.

“There is another side to this measles conversation: how we’ve unintentionally shifted the burden of disease to babies and adults, both groups who are more likely to experience complications, by vaccinating all schoolchildren and losing natural immunity.”
Dr. Bob Sears

There is really only one side to this.

Folks who are intentionally not vaccinating their kids are getting measles and other vaccine-preventable diseases and are putting us all at risk to get sick.

After all, the MMR vaccine provides life-long immunity to most people. That’s not the problem.

If we went back to the pre-vaccine era, when everyone got measles naturally, as Dr. Bob seems to be advocating for, not only would those kids have to earn their immunity, but many babies (those who hadn’t had measles yet) and adults (those with immune system problems) would still be at great risk.

Are you starting to see how silly his arguments are?

We almost had measles beat!

Consider that there were just 37 measles cases in the United States in 2004. And that we have already had more than twice that amount this month alone!

And while measles was cyclical in the pre-vaccine era, it shouldn’t be when folks are vaccinated and protected. What happened to the cycles between 1997 and 2007?

“Unlike natural immunity, the measles vaccine does NOT offer lifelong protection. Estimates of its protection average around 15 years, and describe a phenomenon in the vaccine world known as “waning immunity.”
Melissa Floyd

The measles vaccine provides lifelong protection. Waning immunity only refers to protection against mumps. And no, there is no call for a third MMR dose for extra protection against measles.

“The other trend we’ve seen over the past 10 years is an increase in adult measles cases. “
Melissa Floyd

Dr. Bob’s sidekick neglects to mention that in addition to unvaccinated kis with measles, the trend is an increase in measles cases in unvaccinated adults! After all, most folks who get measles in these outbreaks are unvaccinated.

“To recap: by losing natural immunity for measles for children 5-19 years old, we’ve exposed babies, pregnant women, and adults to measles—all vulnerable groups who are more likely to experience serious complications from the disease.”
Melissa Floyd

Perhaps the only true statement that they make – “we’ve exposed babies, pregnant women, and adults to measles—all vulnerable groups who are more likely to experience serious complications from the disease.”

And no, vitamin A is not a proven therapy or measles in developed countries. It mainly helps prevent complications in kids who have a vitamin A deficiency.

Hopefully, it is becoming evident that what we need to stop is the anti-vaccine propaganda that keeps folks from vaccinating and protecting their kids. We need to stop the outbreaks.

Is January Usually a Big Measles Month?

This year is just getting started, but we already have reports of 86 92 94 measles cases in 7 states, and we haven’t even reached the end of January.

Is that a lot?

Well, let’s compare to previous years…

Is January Usually a Big Measles Month?

Classically, in the pre-vaccine era and in parts of the world that still have endemic measles, rates of this vaccine-preventable disease are highest:

during the late winter and early spring (temperate climates, like the United States)
after the rainy season (tropical climates)

In the post-vaccine era, measles season seemed to shift a little later, to the spring and early summer. In 1994, for example, when we had 963 cases of measles in the United States, 79% of those cases occurred between April and July.

January is not typically a big month for measles.

Similarly, in 2011, we had only seen 15% of the year’s total measles cases by April 1. By August 1, that was up to about 70%.

We do see measles cases year round though, we just seem to see more of them in the spring and early summer months. Since most measles outbreaks in the United States are imported from other parts of the world, you might expect that we would see more cases when folks are traveling more and when there are big outbreaks in other parts of the world.

Unfortunately, measles is on the rise in many parts of the world right now.

And that is likely why we have already seen more cases this month than in the entire year of 2000 (86 cases), 2002 (44 cases), 2003 (55 cases), 2004 (37 cases), 2005 (66 cases), 2006 (66 cases), 2007 (55 cases), 2009 (71 cases), 2010 (61 cases), and 2016 (86 cases).

Year	January Measles Cases	Total Cases
1991	596	9,643
1992	49	2,200
1993	17	312
1994	6	963
1995	22	309
1996	2	508
2008	1	140
2011	8	220
2013	7	187
2014	15	667
2015	108	188
2018	8	355
2019	94	?

As you can see from the above table, January is not typically a big month for measles.

But what happened in 2015? There were a lot of measles cases in January, but we ended the year with only a moderate amount of cases.

That January spike was the California outbreak that had begun in December 2014. By February 2015, there were at least 125 cases, but fortunately no other large outbreaks the rest of the year.

Could that happen this year?

Could the ongoing outbreaks in New York and the Pacific Northwest stop and we then end up with only a moderate amount of cases?

Let’s hope so.

Let’s hope that having the second highest number of measles cases in January since 1991 ends up being the only record we set this year.

Show Me the Vaccine Insert!

Have you ever wondered why anti-vaccine folks always ask about vaccine inserts?

It will soon be obvious that anti-vaccine folks don't really read vaccine inserts... — It will soon be obvious that anti-vaccine folks don’t really read vaccine inserts…

Would they really be happy if we handed them the entire vaccine insert before every visit?

Would they read the entire vaccine insert?

Which part of the vaccine insert do anti-vaccine even read? — Which part of the vaccine insert do anti-vaccine folks even read?

Or would they continue to only believe the parts that they think justify their decisions to leave their kids unvaccinated, unprotected, and at risk for getting life-threatening diseases?

Show Me the Vaccine Insert!

Let’s see what’s really in these package inserts…

“Measles, mumps, and rubella are three common childhood diseases, caused by measles virus, mumps virus (paramyxoviruses), and rubella virus (togavirus), respectively, that may be associated with serious complications and/or death. For example, pneumonia and encephalitis are caused by measles. Mumps is associated with aseptic meningitis, deafness and orchitis; and rubella during pregnancy may cause congenital rubella syndrome in the infants of infected mothers”
MMR II Package Insert

Wait a second!

How can anti-vaccine folks say that measles is a mild disease if the vaccine insert says that it “may be associated with serious complications and/or death.”

Have they really read this thing?

“The impact of measles, mumps, and rubella vaccination on the natural history of each disease in the United States can be quantified by comparing the maximum number of measles, mumps, and rubella cases reported in a given year prior to vaccine use to the number of cases of each disease reported in 1995. For measles, 894,134 cases reported in 1941 compared to 288 cases reported in 1995 resulted in a 99.97% decrease in reported cases; for mumps, 152,209 cases reported in 1968 compared to 840 cases reported in 1995 resulted in a 99.45% decrease in reported cases; and for rubella, 57,686 cases reported in 1969 compared to 200 cases reported in 1995 resulted in a 99.65% decrease”
MMR II Package Insert

Full stop!

How can they say vaccines don’t work when the package insert provides these stats showing it does and goes on to say that “M-M-R II is highly immunogenic and generally well tolerated.”

“The recommended age for primary vaccination is 12 to 15 months.”
MMR II Package Insert

Why are some of these folks delaying or skipping their child’s MMR vaccine? The package insert says to give it at 12 to 15 months!

“Individuals first vaccinated at 12 months of age or older should be revaccinated prior to elementary school entry.”
MMR II Package Insert

That’s the part of the package insert that says to give a second dose before kids enter kindergarten.

“There are no reports of transmission of live attenuated measles or mumps viruses from vaccinees to susceptible contacts.”
MMR II Package Insert

And that’s the part that says they can stop talking about shedding.

Maybe we should make anti-vaccine folks read these inserts…

“The following adverse reactions are listed in decreasing order of severity, without regard to causality, within each body system category and have been reported during clinical trials, with use of the marketed vaccine, or with use of monovalent or bivalent vaccine containing measles, mumps, or rubella:”
MMR II Package Insert

Do anti-vaccine folks understand that some of the things that are listed in the adverse reactions section of the package insert haven’t actually been proven to be caused by the vaccine? They are listed “without regard to causality.”

When you see them talk about SIDS and autism and package inserts, this is what they are talking about.

What about all of the “hidden” ingredients that are listed in the package insert?

Vaccine ingredients are not hard to find.

The ingredients that are so well hidden, they are listed right in the vaccine’s insert? Where does it mention all of the toxins that anti-vaccine folks are always talking about?

“…M-M-R II is highly immunogenic and generally well tolerated.”
MMR II Package Insert

The MMR vaccine works and it is safe.

It says so in the package insert.

Vaccinate your kids.

Is a Vaccine Strain Causing The Latest Measles Outbreak?

What’s the first question anti-vaccine folks start asking whenever we see a large outbreak of measles?

No, it’s not how can I get my kids vaccinated and protected so that they don’t get measles…

It is whether or not it a vaccine strain of measles started the outbreak.

Where do folks get all of this stuff about genotypes and vaccine strains? I wonder…

Dr. Bob had no facts, but still posted that a vaccine strain of measles could have killed a woman who got caught up in the last measles outbreak in Washington.

Yup.

The usual suspects.

Is a Vaccine Strain Causing The Latest Measles Outbreak?

Why do folks who intentionally don’t vaccinate their kids desperately want these measles outbreaks to be caused by a vaccine strain?

Because then it isn’t their fault that their kids are at risk of getting a life-threatening disease!

It’s never a vaccine strain though.

Remember the Disneyland measles outbreak. A lot of folks were talking about vaccine strains when it first started.

“…California patients were genotyped; all were measles genotype B3, which has caused a large outbreak recently in the Philippines…”
Measles Outbreak — California, Dec 2014–Feb 2015

It wasn’t a vaccine strain.

Outbreaks	Year	Genotype
Minnesota	2017	B3
Tennessee	2016	B3
California	2015	B3
Florida	2013	D8
California	2014	B3, D8
Brooklyn	2013	D8
North Carolina	2013	D8
Minnesota	2011	B3
Washington, Illinois	2008	D5, D4

For example, during 2011, 222 cases of measles and 17 outbreaks were reported in the United States, with most cases originating from just five countries (France, Italy, Romania, Spain, and Germany). Six different genotypes were identified, including B3, D4, G3, D8, H1, and D9. No vaccine strains…

And no, it doesn’t matter that the vaccine strain of measles, genotype A, differs from all of the wild strains of measles we see in the outbreaks.

“Vaccine induced immunity protects against all virus strains. Measles is considered a monotypic virus despite the genetic variations.”
Factsheet about measles

Unlike the flu, HPV, and pneumococcal bacteria, in which vaccines only protect against different serotypes, in the case of measles, the genotype simply helps us figure out where the measles case came from.

And no, the latest outbreak, wherever it is, wasn’t caused by shedding from a vaccine.

But if it isn’t the vaccine strain, then why do they that is it important to rapidly identify wild strains vs vaccine strains?

“During measles outbreaks, it is important to be able to rapidly distinguish between measles cases and vaccine reactions to avoid unnecessary outbreak response measures such as case isolation and contact investigations.”
Roy et al on Rapid Identification of Measles Virus Vaccine Genotype by Real-Time PCR

That’s easy to answer.

Outbreaks typically trigger a lot of folks to get vaccinated. While that’s great, one possible problem is that some of those folks might develop a fever and/or rash after their MMR vaccine. So it is important to quickly figure out whether they are part of the outbreak and have a wild strain (maybe they were exposed before their vaccine could start to work) or are having a common, mild vaccine reaction.

But couldn’t they have vaccine-associated measles if they have a rash and fever and a vaccine strain? Theoretically, but then they would likely have true measles symptoms. And even in these rare case reports, the children didn’t spread the measles to anyone else.

So why are you waiting to know the genotype of the measles strain causing the outbreak in your area? Hopefully, it isn’t to help you decide whether or not to vaccinate and protect your kids. While it is interesting to know where the outbreak originated, you can bet that it isn’t a vaccine strain.

The Pacific Northwest Measles Outbreak of 2019

Breaking News – There is 1 new case in Clark County (64 cases), bringing the total case count to 69 cases.

It started with a confirmed case of measles in a child in late December.

The Pacific Northwest measles outbreak on 2019 started when a child exposed others in the area in late December.

There were soon reports of more cases.

The Clark County measles outbreak quickly grew.

And more cases.

The Pacific Northwest Measles Outbreak of 2019

But the measles cases didn’t stay in Clark County.

Two of the unvaccinated kids from Clark County traveled to Hawaii while they were contagious.

As with other recent large measles outbreaks, cases soon spread to neighboring counties.

As of late January, there are now measles cases linked to this ongoing outbreak in Clark County and King County (Washington) and Multnomah County (Oregon).

The rapid growth of the outbreak led Clark County to declare a local public health emergency and Washington’ governor to declare a State of Emergency in all counties in the state of Washington.

“The measles outbreak and its effects impact the life and health of our people, as well as the economy of Washington State, and is a public disaster that affects life, health, property or the public peace.”
Governor Jay Inslee on proclaiming a State of Emergency

Why so much concern?

Are you familiar with the immunization rates in this part of the country? About the only good thing you can say about Washington’s immunization rates are that they are better than Oregon‘s…

Washington has one of the highest rates of exemptions in the United States.

That’s right.

High non-medical vaccine exemption rates and low vaccination rates. A recipe for very large outbreaks of vaccine-preventable diseases, especially measles which is so highly contagious.

Immunization rates by county in Washington.

And a recipe for disaster. These outbreaks are getting harder to control, are lasting longer, and are getting bigger and bigger.

Also remember that the last measles death in the United States, in 2015, was a woman who got caught up in a measles outbreak in Clallam County. Why didn’t that trigger folks in the area to get Vaccinated?

Pacific Northwest Measles Outbreak of 2019
Clark County (WA)	61 cases
King County (WA)	1 case
Multonomah County (OR)	4 case
	69 cases

How many of them are vaccinated? Anti-vaccine folks are pushing hard to convince folks that everyone in the outbreaks are vaccinated. Don’t believe them!

As in most outbreaks, almost all of the people in this outbreak are unvaccinated.

How many people will get sick in the Pacific Northwest Measles Outbreak of 2019 before it ends?

You will have to make an extra appointment if you followed his immunization plan and left your kids unvaccinated and at risk during this outbreak.

Are parents going to keep listening to anti-vaccine folks who push the idea that measles isn’t that bad and make you think that it is riskier to get vaccinated?

Are they going to realize that unless they are malnourished or have a vitamin deficiency, that taking extra vitamin A that you order from someone’s online store will not reduce their risk of severe complications if their unvaccinated child gets measles?

“Please contact your pediatrician or doctor if your child is scary sick, struggling to breathe or unable to eat or very lethargic or otherwise seriously ill. Let them know you are worried they may have measles so they can arrange not to contaminate the waiting room or the whole office.”
Paul Thomas, Integrative Pediatrician

Getting vaccinated can help keep your kids from getting “scary sick” from measles…

“The above recommendations are informational only. Please consult with your doctor before implementing anything you might learn here.”
Paul Thomas, Integrative Pediatrician

The only good advice he gives.

Anti-vaccine misinformation has gotten us to the place where these outbreaks are becoming more common. Vaccinate your kids so they don’t get measles and don’t expose anyone else.

And for the anti-vaccine folks who are asking:

it isn’t going to be shedding or a vaccine strain that caused the outbreak
everyone or almost everyone in the outbreak is going to be unvaccinated
the measles vaccine does work against all the different genotypes of measles
more people don’t die from getting the MMR or any other vaccine than from the diseases they protect us against
whether the death rate of measles is 1 in 1000 or 1 in 10,000 cases, remember that just before the measles vaccine came out, in the early 1960s, nearly 500 people would die of measles each year. And it isn’t that a person dies after 1,000 or 10,000 cases. With more cases, there is just a higher chance that someone will eventually die.

And you are still worried about the MMR vaccine because anti-folks are still scaring you away from vaccinating and protecting your kids.

Vaccines are safe and necessary with few risks. There is no good reason that we should still have outbreaks like this.

Is a Family History of Altered Immunocompetence a Contraindication to Getting Vaccinated?

Have you ever wondered why a “family history of altered immunocompetence” is listed as a contraindication to getting varicella and MMR vaccines?

If family members have altered immunocompetence, getting and exposing them to measles isn't a good idea either. — If family members have altered immunocompetence, getting and exposing them to measles isn’t a good idea either.

It’s probably not why you think…

Is a Family History of Altered Immunocompetence a Contraindication to Getting Vaccinated?

Which vaccines are contraindicated if you have a family history of altered immunocompetence?

Typically MMR and Varivax, the chicken pox vaccine.

Is this about side effects?

Kind of.

As they are live vaccines, you don’t usually want to give them to anyone who might be immunocompromised. And since some conditions that cause immune system problems can run in families, if there is a family history of these conditions, you want to make sure your child doesn’t have one before they are vaccinated.

(g) family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents and siblings), unless the immune competence of the potential vaccine recipient has been substantiated clinically or verified by a laboratory.

General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP)

Fortunately, these types of severe immune problems are rare.

They might include:

Severe antibody deficiencies (e.g., X-linked agammaglobulinemia and common variable immunodeficiency)
Complete defects (e.g., SCID disease, complete DiGeorge syndrome)
Partial defects (e.g., most patients with DiGeorge syndrome, Wiskott-Aldrich syndrome, ataxia- telangiectasia)
Phagocytic deficiencies that are undefined or accompanied by defects in T-cell and NK cell dysfunction (such as a Chediak-Higashi syndrome, Leukocyte Adhesion Deficiency [LAD], and myeloperoxidase deficiency)

Talk to your pediatrician if your child has a first degree relative with one of these conditions, before they get their MMR or chicken pox vaccines.

Still, by twelve months, infants with a severe congenital or hereditary immunodeficiency or any other severe immunodeficiency will almost certainly have symptoms already.

Most children, for example, had been diagnosed with severe combined immunodeficiency (SCID), in early infancy when they have severe and life-threatening infections and failure to thrive.

And most newborns in the United States are now screened for SCID as a part of their routine newborn screening test, and can be diagnosed and treated before they have symptoms! That’s also long before they might be due for their MMR or chicken pox vaccines.

So, if your child has a family history of congenital or hereditary immunodeficiency, and it is in a first-degree relative, but has no symptoms themselves, then they can get safely vaccinated on schedule.

Not surprisingly, anti-vaccine folks try to abuse their family history of altered immunocompetence as an vaccine exemption, even when their own child isn’t immunosuppressed!

VAXOPEDIA

About Those Vaccine Strains in Measles Outbreaks…

About Those Vaccine Strains in Measles Outbreaks…

More on Vaccine Strains in Measles Outbreaks