Amid ongoing measles outbreaks and the threatened return of other vaccine-preventable diseases, we begin with a single case that speaks to the intensity of resistance some parents have to childhood immunizations.
A six-year-old boy in Oregon, who had never received the tetanus shot or other routine childhood immunizations, cut his forehead while playing outside. His parents cleaned and sutured the wound, but six days later, an infection developed likely due to Clostridium tetani, bacterial spores commonly found in soil, the Centers for Disease Control and Prevention (CDC) reports.1
The diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is recommended for children under seven, with the first three doses given to infants at two, four, and six months. The vaccine is a large part of the reason there has been a 95% decrease in tetanus — including a 99% reduction in fatal infections — since the 1940s, the CDC reports. If not given, however, the vaccine is 100% ineffective.
The child in Oregon began experiencing brutal neuromuscular symptoms associated with this infection.
These included “episodes of crying, jaw clenching, and involuntary upper extremity muscle spasms, followed by arching of the neck and back, and generalized spasticity,” the CDC reports. “Later that day, at the onset of breathing difficulty, the parents contacted emergency medical services, who air-transported him directly to a tertiary pediatric medical center.”
Diagnosed with tetanus, the boy was an inpatient in a pediatric ICU for 47 days, so sensitive to light and sound he wore earplugs under care in a darkened room. “He was alert and requested water but was unable to open his mouth,” the CDC noted.
Spasms and respiratory distress set in, and the child was sedated, intubated, and placed on a vent.
Tetanus immune globulin and DTaP were given, and the patient received IV treatment to block muscle spasms and control pain and blood pressure. A tracheostomy was placed for prolonged ventilator support and was not removed for 30 days.
After the child recovered, the ICU stay was followed by more than two weeks of additional rehabilitation therapy. He completely recovered after receiving medical care costing some $812,000. Despite that cost and the near death of their child, the parents made an astonishing decision.
Although clinicians explained that tetanus infection does not confer immunity — meaning the child needed to complete the vaccination schedule to avoid future infections — the family declined all immunizations, the CDC concludes.
“Now that’s an antivaccination family,” says William Schaffner, MD, professor of preventive medicine at Vanderbilt University. “Despite their son’s incredible life-threating illness, they still declined vaccination.”
Albeit extreme, this is the kind of mindset vaccine advocates are up against. The CDC “describes this very concisely, but you cannot imagine the agony of this illness for this child,” he says.
A nationally known vaccine advocate, Schaffner says clinicians and public health are in for a protracted battle to overcome resistance to vaccinations. For example, better health education is needed in schools to teach children about vaccines and the untold number of lives saved by them. (See related story in this issue.) At present, one of the greatest public health achievements of all time is being eclipsed by misinformation and rumor. For example, smallpox — a scourge on mankind for thousands of years — was eradicated in the wild by vaccination.
The major reason people now have “vaccine hesitancy” is because immunization has been so successful that the diseases they are designed to prevent have been essentially eliminated in the U.S., he says. “Young parents do not have any experience with these diseases growing up,” he says. “They don’t know them. If you don’t know the disease, and respect or even fear it, you won’t value the vaccine.”
Science Strikes Back
Although it has been amplified exponentially by the internet, the anti-vaccine movement is generally traced to an infamous 1998 article in The Lancet that fueled fears that the measles-mumps-rubella (MMR) vaccine may cause autism. This article was “proven to be false” and fully retracted by the journal in 2010 after years of criticism from the medical community.2
Science recently struck back, with a massive study involving more than 650,000 children in Denmark. The researchers compared autism rates in unvaccinated children and those who had been immunized against measles, finding that “MMR vaccination does not increase the risk for autism, does not trigger autism in susceptible children, and is not associated with clustering of autism cases after vaccination.”3
“That is a huge, powerful study,” Schaffner says. “The Danes have medical care from birth to death, and they have a totally comprehensive medical record on everybody.”
With the current appeal and constant repetition of various and sundry conspiracy theories, Schaffner says it was just as well the study was not published in the U.S.
“It is important that it was done in Denmark and not in the United States,” he says.
“I have heard on occasion from antivaccine folks that we in the U.S. have created this ‘myth’ of vaccine safety.”
Added to the accumulated weight of preceding data, the Danish study should finally put the autism-MMR link to the sword. “If this doesn’t put — at least scientifically — the question to rest, nothing ever will,” Schaffner says. “But I don’t think the antivaccine folks will be convinced. They have not been moved by data in the past.”
Anecdotal Reports
Indeed, many websites and social media platforms are riddled with vaccine misinformation, says Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology.
“We know that vaccines are the safest proven way to prevent disease,” she says, adding that she recently tried to make this very point to a relative at a family gathering. Hoffmann said one of her relatives explained she was not immunizing her child because her pediatrician said that all of the vaccines are not necessary.
Such anecdotal accounts are not uncommon, as a recently published commentary by public health experts cited “some pediatricians who publicly cast doubt on vaccine safety.” Given the ongoing outbreaks and inconsistent state laws, the authors called for the federal government to mandate vaccinations.4
Asked to respond, the American Academy of Pediatrics (AAP) said it was of aware of no such reports involving its 67,000 members. However, the AAP added, not all pediatricians are members of the group.
Given the situation, Washington state was taking legal action to remove personal exemptions as this report was filed.
Jonathan McCullers, MD, chief pediatrician at Le Bonheur Children’s Hospital in Knoxville, TN, outlined the current state regulations at a recent Congressional hearing on the issue.
“Three states currently only allow medical exemptions from vaccination — California, Mississippi, and West Virginia. These states all have vaccination rates for measles at the age of school entry at 97% or better — above the 96% level needed for herd immunity.”
However, 30 states allow for religious vaccine exemption, and 17 allow both religious and “personal” exemptions, he added. “Allowing multiple pathways to exemption worsens this problem,” he said.
“Of the five states that have less than 91% vaccination rates — Colorado, Idaho, Indiana, Kansas, and Washington — three allow both types of exemptions.”
In California, both types of exemptions were allowed until a large measles outbreak at Disneyland in 2014-2015 prompted revisions in the law.
They “eliminated non-medical exemptions, and the vaccination rate has returned to 97%,” McCullers said.
Another factor in the California outbreaks was the practice by some parents of delaying or spacing out childhood vaccines instead of correctly following the immunization schedule.
“The vaccine against measles is very safe and effective,” he said. “The first dose of MMR protects about 93% of children, while a second dose extends immunity to 97%. Very few side effects occur.”
In that regard, about one in 10 children experience fever for a day or two. About one in every 3,500 children will have “a simple seizure” with fever, but no lasting effects.
“Allergic reactions are very rare and typically very mild,” McCullers said. “No reactions or adverse effects of a more severe nature have been associated with the vaccine despite extensive use, monitoring, and study for many decades.”
Considering all childhood vaccines, immunization programs in the U.S. prevent more than 1 million infections and more than 10,000 deaths from disease every year, testified Saad B. Omer, MBBS, MPH, PhD, a professor of epidemiology and pediatrics at Emory University in Atlanta. “To put that into perspective in the current day,” he said at the hearing, “without childhood vaccines, the states of Tennessee and Washington would be dealing with between 24,000 and 37,000 vaccine-preventable diseases in an average year, and between 250 and 275 children would die, most of them under the age of five.”
Currently, measles is hovering close to the herd immunity “threshold,” meaning as the vaccination level of the population drops below 97%, more widespread outbreaks become likely, he said.
REFERENCES
- Guzman-Cottrill JA, Lancioni C, Eriksson C, Cho Y, Liko J. Notes from the Field: Tetanus in an Unvaccinated Child — Oregon, 2017. MMWR 2019;68:231–232. DOI: http://dx.doi.org/10.15585/mmwr.mm6809a3.
- Editors of The Lancet: Retraction—Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 2010;375:445.
- Hviid A, Hansen JV, Frisch M, et al. Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. Ann Intern Med 2019; DOI: 10.7326/M18-2101.
- Ratzan SC, Bloom BR, Gostin LO, et al. States are failing on vaccinations. The federal government must lead. Washington Post. March 7, 2019. Available at: https://wapo.st/2J3ydP2.
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