Pertussis returns in states with lax vaccination laws

As I mentioned on Friday, I’m in Chicago right now attending the American College of Surgeons annual meeting, where I was until last evening. Unfortunately, I got back too late and was too tired to lay down some fresh Insolence, Respectful or otherwise. Fear not, though. I’ll get to it. In the meantime, here’s a blast from the past from the past. This post first reared its ugly head almost exactly three years ago; so if you haven’t been reading at least three years, it’s new to you.

By the way, even though this post is three years old, the problem described in it has only gotten worse in the interim.

I’m with Kevin, M.D. on this one. Not giving required vaccinations is akin to child neglect:

CHICAGO – State laws that make it easy for children to skip school-required vaccinations may be contributing to whooping cough outbreaks around the country, a study suggests.

All states allow children to be exempted from school immunization requirements for medical reasons — because they might have a bad reaction, for example, or have weak immune systems — and 48 states allow exemptions for personal or religious beliefs.

To get non-medical exemptions, some states require documentation, notarized paperwork and even visits to a local health department. In other states, parents merely have to sign an exemption letter.

Compared with stricter states, those with easy exemption policies had about 50 percent more whooping cough cases, according to the study. Also, about 50 percent more people got whooping cough in states that allowed personal-belief exemptions, compared with those allowing only religious exemptions, the study found.

Here’s the study:

Nonmedical Exemptions to School Immunization Requirements: Secular Trends and Association of State Policies With Pertussis Incidence

Saad B. Omer, MBBS, MPH; William K. Y. Pan, DrPH, MS, MPH; Neal A. Halsey, MD; Shannon Stokley, MPH; Lawrence H. Moulton, PhD; Ann Marie Navar, MHS; Mathew Pierce, JD, MPH; Daniel A. Salmon, PhD, MPH

JAMA. 2006;296:1757-1763.

Context: School immunization requirements have played a major role in controlling vaccine-preventable diseases in the United States. Most states offer nonmedical exemptions to school requirements (religious or personal belief). Exemptors are at increased risk of acquiring and transmitting disease. The role of exemption policies may be especially important for pertussis, which is endemic in the United States.

Objective: To determine if (1) the rates of nonmedical exemptions differ and have been increasing in states that offer only religious vs personal belief exemptions; (2) the rates of nonmedical exemptions differ and have been increasing in states that have easy vs medium and easy vs difficult processes for obtaining exemptions; and (3) pertussis incidence is associated with policies of granting personal belief exemptions, ease of obtaining exemptions, and acceptance of parental signature as sufficient proof of compliance with school immunization requirements.

Design, Setting, and Participants: We analyzed 1991 through 2004 state-level rates of nonmedical exemptions at school entry and 1986 through 2004 pertussis incidence data for individuals aged 18 years or younger.

Main Outcome Measures: State-level exemption rates and pertussis incidence.

Results: From 2001 through 2004, states that permitted personal belief exemptions had higher nonmedical exemption rates than states that offered only religious exemptions, and states that easily granted exemptions had higher nonmedical exemption rates in 2002 through 2003 compared with states with medium and difficult exemption processes. The mean exemption rate increased an average of 6% per year, from 0.99% in 1991 to 2.54% in 2004, among states that offered personal belief exemptions. In states that easily granted exemptions, the rate increased 5% per year, from 1.26% in 1991 to 2.51% in 2004. No statistically significant change was seen in states that offered only religious exemptions or that had medium and difficult exemption processes. In multivariate analyses adjusting for demographics, easier granting of exemptions (incidence rate ratio = 1.53; 95% confidence interval, 1.10-2.14) and availability of personal belief exemptions (incidence rate ratio = 1.48; 95% confidence interval, 1.03-2.13) were associated with increased pertussis incidence.

Conclusions: Permitting personal belief exemptions and easily granting exemptions are associated with higher and increasing nonmedical US exemption rates. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence. States should examine their exemption policies to ensure control of pertussis and other vaccine-preventable diseases.

Although one can quibble about its methodology, the results of this study, in which lax vaccination polices tend to correlate with higher rates of pertussis on a state-by-state basis, should come as no real surprise. The effectiveness of the pertussis vaccine depends upon herd immunity, where high levels of vaccination keep an infectious disease from spreading among the few unvaccinated and those in whom the vaccine is not offering adequate protection. (No vaccine is 100% effective; so there will always some percentage of even a vaccinated population that is susceptible to the disease vaccinated against. Antivaxers often distort, exaggerate, or misrepresent this fact to question whether vaccinations are efficacious at all.) As I’ve pointed out before, in places like Boulder, Colorado, where wealthy alties have refused to vaccinate their children in droves, pertussis has returned with a vengeance. And we may be seeing the same thing here, as the study found:

Children with nonmedical exemptions are at increased risk of disease and they increase community risk of disease transmission. From 1985 through 1992, exemptors in all states were 35 times more likely to contract measles than nonexempt children. In Colorado, exemptors were 22 times more likely to have had measles and 5.9 times more likely to have had pertussis than vaccinated children. Moreover, the incidence of measles and pertussis in nonexempt children in a county was associated with the frequency of exemptors in that county.

That’s an incredible difference.

Because the rates of once-feared diseases like pertussis have fallen so low, thanks to vaccinations, people have forgotten how horrible these diseases could be. For an example of just how warped this thinking can become, I was made aware of a discussion on Mothering.com. In this discussion, a mother by the ‘nym of Momtezuma Tuatara is practically ebullient at reports from New Zealand claiming that the vaccine is a “dud,” when in fact that is not what the reports claim. For example, this 2004 report states about the latest epidemic of pertussis there:

Vaccination information was recorded for 2181 (62.5%) cases. A total of 34 cases had received all five doses of vaccine, 146 had received four doses and 285 were in receipt of three vaccine doses. Across all age groups, the proportion of cases vaccinated was 49.4% (1725/3489). Surveillance data show that only 47.5% (47/99) of those aged 4 months or less, had received the vaccines for which they were eligible (see Table 13).

In other words, the vast majority of the cases had not received all of the recommended doses of the vaccine, and it was noted that more adults were coming down with the disease:

The immunity provided by vaccination does not last through adulthood and is not 100% effective. Therefore it is important that children are immunised on time according to the immunisation schedule. The 2004 epidemic has highlighted the need for a strategy to control the persisting pool of infection in the adult population.

But in the woo world of antivaccination zealots, this sort of data is “validation” of their belief that vaccines don’t work:

I like seeing my ideas confirmed and that is that despite these vaccinations, all the diseases come and go as they please in frequency.

Of course, in this world, “natural” immunity is assumed without question to be better than any immunity induced by vaccine:

So I think that not only is the vaccine far less effective than widely claimed/considered, what we are seeing is the long-term result of replacing natural immunity with vaccine immunity, with a much larger percentage of adults and older children being non-immune and capable of transmitting the infection (which is often subclinical or milder in these age groups as compared to in the younger age groups in which it “prefers” to occur, and who more often exhibit clinical symptoms).

I also think there may be some maternal immunity which has been lost with the loss of widespread natural immunity, which also leaves infants more vulnerable to infection. JMO.

And:

Natural immunity to Pertussis is undoubtedly superior to anything produced by the vaccine. The aluminum in the killed vaccine stimulates an antibody response but not a cell-mediated response. Natural infection stimulates the entire immune system.

There it is again, the faith in the “natural” as being inherently and automatically superior to anything conventional medicine can do, which is viewed as “unnatural.” And, as is the case in alternative cancer therapies, for example, this belief in “natural immunity” leads to irresponsible and potentially dangerous practices. In the case of chickenpox, for example, some parents are holding “pox parties“:

It sounds like a plot line from The Simpsons. In fact, it is a plot line from The Simpsons. Who else but America’s favorite dunderhead, Homer Simpson, would do such a thing?

Surprisingly, pox parties are popping up in neighborhoods in several U.S. cities. On Internet bulletin boards and blogs, rumors spread that the chickenpox vaccine is somehow unsafe or ineffective. Parents worried by these rumors join email rings. When one of these parents’ children gets chickenpox, the parents invite others in the community to a pox party…

A “natural mothering” web site gives a recipe for spreading varicella zoster virus — the chickenpox germ. It advises parents to pass a whistle from the infected child to other children.

“It is absolute lunacy,” UCLA infectious disease specialist Peter Katona, MD, tells WebMD.

Adults who get chickenpox for the first time get a much more serious disease than do children. But even for children, chickenpox isn’t a walk in the park. And every once in a while, a child gets a very serious form of the disease. One in 50,000 kids gets a brain infection that causes retardation or death. And itchy chickenpox blisters can get infected with dangerous bacteria.

“Imagine losing a child because you were dumb enough to bring him to a pox party,” Gershon says.

Indeed. Back in the days before the availability of the chickenpox vaccine, pox parties were not quite as irrational as they sound now because there was no other way to achieve immunity to the varicella virus. Considering them in context of the times, they were somewhat understandable. Even so, that doesn’t mean they were a good idea, even then. Parents were still taking a chance, as fellow SBer Tara Smith pointed out several months ago:

Additionally, the wild virus just ain’t as benign as we’d like to think. It can cause severe pneumonia or encephalitis. Additionally, I mentioned here that deadly infections with the group A streptococcus are becoming more common. Guess what’s a major risk factor for these infections? Yep–chicken pox. Check out, for example, this manuscript on invasive group A strep disease in Alberta, Canada, which notes that “varicella virus infection preceded invasive GAS disease in 25% of children 8 years of age and under.” It has the potential to be much more than just an inconvenient itch.

And, I would add, in children with compromised immune systems, varicella infection can be deadly. Yes, the vast majority of children who get chickenpox recover uneventfully, but a number of these can suffer serious complications. Overall, the vaccine has minimal risk, and it prevents disease in children and the later development of shingles in adults.

This attitude that “natural immunity” is inherently “better” than permeates antivax websites. For example:

Exchange your faith in: Natural immunity only comes after a disease.
With faith in: Natural immunity comes with Health, a ‘clean blood stream that is well nurished’.

Exchange your faith in: Disease is dangerous.
With faith in: Healing activity (typically called disease symptoms) is a process that is natural, beneficial, and far safer than generally recognized.

Personally, I think I’ll keep my view that vaccine preventable diseases like polio or pertussis are dangerous, thank you very much. One has to wonder, of course, if diseases aren’t “dangerous,” then why bother to try to prevent or treat them? That does seem to be the attitude behind a lot of this antivaccination lunacy. After all, those nasty symptoms that can result in paralysis in polio, for example, are nothing more than manifestiations of “healing activity.” Apparently it’s better to let your child suffer the horrendous symptoms of pertussis, with the risk of the need for hospitalization and even the possibility of death. And, make no mistake, pertussis can be a horrible disease, complicated by pneumonia and occasionally death.

Although antivaccination mania goes back a long time, I wonder if this this extreme faith in the natural and belief that the symptoms of disease are a healing crisis” whose symptoms shouldn’t be interfered with may be traceable, at least in modern times, back to Ryke Geerd Hamer, a German physician who developed a concept that diseases, especially cancers, aren’t dangerous in and of themselves but rather are manifestations of a mental conflict. Indeed, he formulated what became known as German New Medicine, complete with various “rules” and “laws” (in fact, total woo) based on this concepts, such as the First Biological Law: The Iron Rule of Cancer. The bottom line from Dr. Hamer’s and other altie doctors for antivaxers is that disease isn’t really as dangerous as doctors tell you that it is, that vaccines are an unnatural assault on the immune system, and that disease is due more to internal factors (such as mental stress or a tragedy) than it is to bacteria or viruses. Of course, Dr. Hamer didn’t originate such concepts himself, but he popularized them, at least in Europe.

The results of this study suggest that, the easier it is to get an exemption from vaccination for schools, the more an infectious disease like pertussis can spread and the more herd immunity can be compromised, thus endangering even the vaccinated. Worse, it is clear that attitudes such as those expressed on the Mothering.com forums and by utter loons like Dawn Winkler (there’s just no other word that describes her), the Libertarian candidate for Governor of Colorado, are on the increase. Yes, I’m very afraid that it will take a huge and deadly resurgence of vaccine-preventable diseases to remind people of the reasons that these vaccinations were developed in the first place. It wasn’t to “enrich the pharmaceutical companies.” It wasn’t to enrich doctors. It wasn’t because conventional medicine want’s to inject “filth” into your children. It was to protect children from epidemic diseases that caused incredible suffering and death until as recently as a few decades ago. And these diseases never went away, either. They are still there, waiting to return.

ADDENDUM: I’m sure the antivaxers will pull the “pharma shill” gambit on this particular study, because two of the researchers reported support from pharmaceutical companies. Just wait. Never mind that one of the two isn’t completely convinced that lax vaccination policies are associated with higher pertussis rates.