Should parents vaccinate their children? One pediatrician thinking about measles


Every pediatrician, each in his or her own way, faces those few parents who are afraid to immunize their children. It’s not a dramatic moment. Fairly early in the process of getting to know who this patient is, a parent will say, “It’s too much.” Or, “It will overwhelm his immune system.”

This opens up a new window into who they are, along with a question — will I be able to convince them or not? In a way, it’s basic medicine: You find out something new about someone, and now you have to figure out what it means and what they will need from their doctor. 

The measles virus, like the polio virus, only lives — in the strange way that viruses live — in people. These viruses are part of the natural world. We aim to improve upon nature by getting rid of these illnesses, thereby making this virus extinct, without apology. Smallpox was eradicated in the 20th century. The eradication of polio was a goal within reach, though now it seems to be slipping further from our grasp. 

My father had polio before it was preventable. Both of his legs were paralyzed. In his childhood, he got around on a kind of homemade skateboard, or he was carried like Dickens’ Tiny Tim. After many surgeries a long train ride from home, he got around quite well with a brace and crutches. His handicap was an important part of my formative experience, 30 years after the polio virus had done its damage to him. Of course, I got the polio shots as soon as they were available. And soon after that, I got the oral vaccine too, just to be sure.

Lots of things are complicated, but why is the immunization of children against measles one of them? It should be a no-brainer. Measles is a serious illness, bad enough that it’s worth preventing.  

Antibiotics don’t do anything against measles. Treatment is “supportive,” meaning watch and wait, managing complications as possible. Days of fever of 104 degrees and higher, maybe pneumonia, maybe hospitalization — burning through your deductible — and sometimes permanent consequences. I saw a patient once who was having seizures every minute for years after measles. 

Around the world, measles is still a major cause of mortality in children. Almost all of us over 60 are “survivors”; we had measles when we were little. I had measles and got over it. And I rode around in a car without a car seat or seat belt and survived that, too. Not everyone was so lucky.

Seat belts and car seats save lives. And immunization works. It works so well that U.S. cases, which used to number in the hundreds of thousands every year, have been knocked down to fewer than a hundred, until recently. The MMR vaccine prevents measles, mumps and rubella. Incidentally, we don’t see as much infertility from mumps as we used to. And congenital rubella — a much worse illness than measles — has mostly disappeared from this part of the world, for now. I’ve seen congenital rubella with my own eyes: a frail blind girl, with a tiny brain that didn’t work very well.

Most of the people in the world live in places where measles is seen all the time. Mainly, it’s just one, and not the worst, feature of poverty. Since the continuous circulation of measles ended in the U.S. in 2000, we have had occasional measles outbreaks, each starting with an importation. Since then, measles in the U.S. has mostly been imported by Americans returning from Europe and Asia. Someone inhales the measles virus in the course of his or her adventure. Later, safe at home, a nasty “flu” with “pink eye,” fever and cough ensues. Days pass in misery without any rash. Friends, classmates, co-workers, health care workers are exposed. With every cough, he is spreading measles virus generously around; it lingers for an hour or two wherever he’s been. No one has figured out he has measles yet because the rash comes later. 

Now we come to “herd immunity.” No vaccine works perfectly, meaning that some people get measles when exposed in spite of having been immunized. But for each individual, the chance of getting it is very much reduced by having been immunized. The fewer the people in the “herd” — more felicitously known as the community — are vulnerable, the lower the chance that the “index patient,” the importer, will be able to infect someone else. For those who cannot be immunized — especially babies, people with HIV or on chemotherapy —  “herd immunity” means they hope to get away with being vulnerable because measles won’t start going around if all the contacts of the index patient are immune. 

And because the vaccine isn’t perfect, even those of us who are immunized benefit from the herd, because the fewer people around us have measles, the lower our chance of being in the 1 or 2 percent “vaccine failure” group.

So why is there so much push back? Stumbling blocks were deliberately placed in front of the blind: False and fraudulent assertions of a link between the MMR and autism were made. Although the claims were finally and definitively debunked several years ago, spinoff descendants continue to appear. In the American spirit of “Don’t Tread on Me,” parents — like physicians — don’t want government telling them what to do. And some people believe they can protect their children from all harm if they avoid “toxins” and “chemicals” — never mind the “toxicity” of the diseases themselves to muscles, fertility and sometimes to the brain. Others are leery of “Big Pharma” and the Medical-Industrial complex. And not a few parents are just anxious.

Should a pediatrician refuse to take care of children whose parents refuse immunizations? Should a doctor refuse to see people who are sick? We routinely treat folks who eat too much, watch too much TV, don’t exercise regularly, smoke or drink and put others at risk, and even who ignore good medical advice. Why should some absurd ideas about immunization be a disqualifying condition for having a doctor?  

Very few of us are completely rational, and for those who are, it’s usually seen as a disability. Our judgments of priority are colored by our experiences. I didn’t need medical school to know that polio was bad. Everyone sees the world from a different point of view. The physician has to start by listening to the patient. Immunizations are important; lots of things are important. 

To what extent is the pediatrician, an agent of the state, charged with enforcing some standard? Our primary obligation is to the children in our care, but we rely on the parents to provide it; there is rather little we can do without their active participation. So pediatricians perform a delicate dance — we have to convince the parents to see it our way. 

But now measles is here. This week, I began requiring my patients who can be immunized to be immunized against the contagious illnesses that could jeopardize my other patients.

I have to take care of the patient that I have in the family that he has, in the context where I find him. Being invited to enter into that world is a privilege, and it’s my main tool. It’s also where the real drama is, and where both healing and prevention begin. But I am reminded that the context of the physician-patient relationship includes the community of my practice — my “herd.”


David H. Keene, M.D. is a pediatrician in Los Angeles.

Day schools see decline in vaccinations


A recent measles outbreak originating at Disneyland that has infected more than 50 people has returned the issue of declining immunization rates to the headlines.

California health officials report that the outbreak began at the Anaheim theme park in mid-December and quickly spread throughout the country, helped along in part by the growing influence of the anti-immunization movement, which sees vaccines as unhealthy and linked to disorders such as autism.

As a number of newspaper and magazine articles have noted, parents who refuse to vaccinate their children tend to be concentrated in affluent, well-educated areas of major U.S. cities — areas that also encompass the majority of Jewish day schools, several of which have non-immunization rates as high as 26 percent.

According to a compilation of state data by the San Francisco-based radio station KQED, 26 percent of kindergarten students last year at the Chabad Academy of San Diego and Beth Hillel Day School in Los Angeles opted out of vaccines last year. In 2012, 14 percent of kindergarten students at the Seattle Hebrew Academy in Washington opted out, according to the radio station KUOW in Seattle.

The statistics are not a perfect guide to immunizations rates. For example, Beth Hillel principal Seth Pozzi explained that the seemingly high rate of non-vaccination was due to several of the children in transitional kindergarten being too young to complete their vaccines. Pozzi said all have since been vaccinated.

The Chabad Academy of San Diego and Seattle Hebrew Academy did not return multiple calls requesting comment.

Variations in state law limit what schools can do about parents who decline vaccinations for their children. In New York, private schools may ban unvaccinated students. But schools in other states have fewer options. According to California law, individual schools have no right to force parents to immunize their children and must accept any student whose parents submit the proper waiver form claiming religious, philosophical or health-related exemptions to immunization. Washington state allows school districts to set more restrictive policies; none has.

“You have a conflict of what state law allows you to do versus what you may want to do individually,” said Donald Zimring, head of school at Brandeis Hillel Day School, a community school whose Marin County campus in northern California’s Bay Area had a 15 percent opt-out rate in 2013. “It would be my personal preference to only admit youngsters who are immunized.”

At Brandeis Hillel’s San Francisco campus, only 5 percent of students opted out in 2013. But even schools with relatively low opt-out rates can pose dangers.

To be effective, vaccines rely upon what is called herd immunity. In the case of the most contagious diseases, like measles and whooping cough, roughly 95 percent of the population must be immunized to ensure that if an infected person should appear, the disease does not spread. This is particularly important to protect the less than 1 percent of the population with an adverse physical reaction to vaccines, such as anaphylaxis, and who thus cannot be vaccinated.

“We eliminated measles transmission in the U.S. in 2000,” said Dr. Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and a strong advocate for universal vaccination. But, he added, “When you have an erosion of herd immunity, the most contagious diseases come back first.”

In New York, private schools have much greater freedom to decide whether to accept parental objections to vaccinations on religious grounds. At the Ramaz School, a Modern Orthodox day school in Manhattan, principal Rabbi Haskel Lookstein issued a ruling that vaccinations are considered pikuach nefesh — a Jewish legal standard under which religious requirements are suspended to protect human life.

“It’s a condition of attending Ramaz,” Paul Shaviv, its head of school, said of vaccinations. “It’s absolutely required for the protection of the health of the students.”

In 2005, the Committee on Jewish Law and Standards of the Conservative movement ruled likewise, unanimously, that vaccination was required under Jewish law, save for medical exceptions. But elsewhere in the country, the rules are not so strict or the community is not so supportive of immunization.

Last August, Rabbi Shmuel Kamenetzky, an influential Charedi Orthodox rabbi in Philadelphia, told the Baltimore Jewish Times, “I see vaccinations as the problem. It’s a hoax. Even the Salk vaccine [against polio] is a hoax. It is just big business.”

In Oregon, only about 1 percent of the student population at the Portland Jewish Academy have vaccination exemptions, according to executive director Steven Albert. But the school is host to afterschool programs that bring in students from other schools, and Albert said it would be impossible for his academy to institute its own vaccine policies for those students.

The issue cuts across denominational lines. Schools with low and high opt-out rates for vaccinations range from community schools to Orthodox. Suspicions that vaccinations lead to ill effects such as autism — a concern unproven by scientific research — affect wealthy, liberal areas such as Marin County and some parts of the Charedi Orthodox world.

But Offit of Children’s Hospital argues that exemptions on both philosophical and religious grounds should be eliminated from state laws, noting that Mississippi and West Virginia offer no exemptions of any kind, save for medical ones, from vaccination requirements.

“The choice to put a child in an unnecessarily risky position is an unreligious act,” Offit said. 

Community Braces for Flu Shot Scarcity


 

Michael Gabai is on a quest.

The owner and administrator of Ayres Residential Care Home has spent the last two weeks calling physicians, senior centers, grocery stores and pharmacies in search of flu shots for about half of the 18 residents in his facilities who have been unable to get one. Gabai was finally able to secure a reservation for his oldest resident, a 96-year-old, to get vaccinated at a grocery store about 10 miles away.

“We’re scrambling to get it done, Gabai said. “We know how easily [flu] can turn into pneumonia for our elderly clients.”

With the flu vaccine shortage becoming a national — and political — crisis, people working with seniors, like Gabai, are the most troubled.

“Flu is always a concern,” said Molly Forrest, director of the Los Angeles Jewish Home for the Aging (JHA). Vaccinations are normally given to all of JHA’s residents and frontline caregivers willing to be inoculated, she said. However, JHA has not yet received its supply of vaccines from the Los Angeles County Department of Health Services, which has promised to deliver them late this month or early in November. Flu season generally spans from November to March, and affects between 10 percent to 20 percent of Americans.

During the 2003-2004 flu season, there were 1,600 deaths from influenza and pneumonia in Los Angeles County, according to the Center for Disease Control. Also, over the last five years, nearly 90 percent of all deaths from flu andpneumonia were among those 65 or older.

Forrest believes they will get adequate amounts of vaccine to cover the residents, but thinks they might need to seek additional doses for frontline staff.

During her nine-year tenure, Forrest said that JHA had not experienced any serious flu outbreaks. When cases have arisen, they have isolated individual buildings or patients in order to contain the spread of the disease.

Jewish Family Service’s (JFS) Valley Storefront and West Hollywood Senior Center had to cancel scheduled flu shot clinics when the Red Cross failed to deliver vaccines as promised, said Lisa Brooks, one of the agency’s directors.

“We’re waiting to see if more supplies become available,” she said. Directors of JFS’s senior centers are in close contact with sources of the vaccine to find out when that might be.

Additional flu shots might soon be forthcoming from drug manufacturer Aventis Pasteur. The majority of its 22.4 million doses, which were promised but not yet shipped to customers, will be routed to entities designated by the Centers for Disease Control and Prevention (CDC) as priorities. In addition to seniors, those considered most at-risk of developing potentially life-threatening complications from the flu include children under 2 years old (the vaccine is not recommended for babies younger than 6 months old), individuals with chronic medical conditions and pregnant women. According to United Press International, CDC Director Dr. Julie Gerberding said the agency is mapping areas where the vaccine has been sent and those where it is needed and also tracking flu cases by county to quickly identify flu hot spots.

The flu shot shortage does not seem to trouble early childhood educators.

“I don’t think at this time anyone is particularly panicking,” said Betty Zeisl, director of public relations and communications for the Bureau of Jewish Education (BJE), who noted that at a meeting of early childhood center directors last week “the subject didn’t come up.” (While BJE facilities must conform to federal, state and local guidelines, protocols for dealing with illness are determined by each individual center.)

“I don’t think [the shortage] is going to affect us,” said Angie Bass, director of the early childhood center at Temple Beth Am, who believes that sensationalized media reports are needlessly scaring parents. Bass said that the school maintains routine health precautions such as undergoing regular cleaning, a hand-washing policy for staff and students and a practice of sending children home if they need to wipe their noses more than three times in a 15-minute period.

Bass said that “if it really looked like a real epidemic and not just media hype,” she would send home a letter informing parents and include advice from pediatricians. Thus far, however, none of the pediatricians she has consulted have expressed concern.

“As soon as the pediatricians are worried, then I’ll worry,” she said.

“I think it is a potential problem,” said Dr. Carol Berkowitz, professor of clinical pediatrics at Harbor-UCLA Medical Center in Torrance and president of the American Academy of Pediatrics. “We never know how serious a flu season we will have.”

At the same time, she said that last year was the first year that vaccination was suggested for healthy children between 6 and 24 months.

“Flu vaccine has never been recommended for healthy children over the age of 2 years,” she added.

Berkowitz and others emphasize the importance of following CDC recommendations to help prevent flu. These include avoiding close contact with people who are sick, staying home from work or school if you are sick, covering your mouth and nose with a tissue when coughing or sneezing, avoiding touching your eyes, nose or mouth and washing your hands frequently. Certain prescription antiviral medications (oseltamivir, rimantadine and amantadine) can either prevent the flu or lessen its symptoms if taken promptly after exposure to the virus — or soon after symptoms begin. Symptoms may include fever, headache, chills, body aches, dry cough, stuffy nose and sore throat.

Unfortunately, even if individuals take precautions, they cannot control the habits of others. As the JHA’s Forrest notes, this is especially true for the most vulnerable populations.

“The very young and very old, who get help from other people, are incredibly at risk because they depend on someone else’s hygiene,” she said.

 

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