Monday, May 12, 2014

Whooping Cough and the Anti-Vaccination Movement

Pediatrics rounds are similar to what I described in one of my initial posts. We spend most of the morning visiting each pediatric patient with the attending physician and deciding on a treatment plan with the parents. Frequently we encounter patients on “contact precaution,” which means they have a highly communicable infection. In order to reduce the transmission of infection, before we enter the room we put on disposable gowns that cover the arms, torso, and upper legs, as well as gloves, and a face mask if the infection is communicable via the air. We fumble around outside the patient’s room, handing gloves, gowns and masks out to each other, donning them as we would some radiation suit. Upon exiting the room, we remove these protective accoutrements and put them in the trash. The CDC recommends this practice, though in certain cases the efficacy of it is unclear.

One morning we saw a six-month-old child on contact precaution with whooping cough, a respiratory sickness caused by the Bordetella pertussis bacteria. We stood outside the child’s room putting on masks before we entered. Inside, the baby’s mother paced back and forth, holding and rocking her son as the infant experienced a series of coughing fits and struggled for the air even to cry. Bacteria had attached to the cells of his upper airway and produced a toxin that prevented those cells from sweeping foreign particles and dirt up out of his throat. Thus, he coughed in order to clear these alien elements that we normally clear silently. He coughed so hard and for so long that he barely had time to breathe in and was perpetually short of breath. At times, he looked and sounded like he was about to die. This not-uncommon response to the infection disturbs us as we must watch an infant struggle for each breath without any effective treatment. We sit back with horror, anticipating the moment when the child ceases to inhale.

At this point, he had already experienced the first stage of the whooping cough sickness, the catarrhal stage. This lasts for the first couple of weeks and presents merely like a common cold, making it unrecognizable from a benign respiratory infection. But this is also the stage at which the bacteria are most contagious, and the only stage at which antibiotics work in preventing progression of the sickness. Many parents unknowingly take their children out into the community without being treated, thus spreading the infection.

The second stage of the disease is the stage our patient was struggling through — it’s called the paroxysmal stage. Though children or adults are less contagious at this stage, their symptoms are far worse and this is the stage with the infamous whooping cough. Patients cough so forcefully that, desperate for air, they take in a huge and sudden inspiration (the whoop) in order to compensate for lost breathing time. Antibiotics only prevent the disease from spreading but have no mitigating effect on symptoms. During the second month of the infection, the disease resolves with the convalescent stage.

Though the eventual outcome sounds benign, the disease does not always resolve as we expect. In fact, the sequelae of this disease are costly and deadly. Half of infants less than one year old with this infection are hospitalized. And among those, 23% get pneumonia, 1.6% will have convulsions, 67% will have apnea (cessation or slowing of breathing), and 1.6% will die. In adults who get pertussis, weight loss, loss of bladder control, syncope (passing out), and rib fractures from severe coughing are also common. But a patient need not experience any of these symptoms, mild or severe, if he or she receives the vaccination against Bordetella pertussis.

Why, if we have a perfectly good preventable measure against these bacteria, do we have six-month-olds gasping for air in the hospital? Unfortunately, in recent years, a popular anti-vaccine movement perpetuated by celebrities and based on shoddy science has discouraged many parents from vaccinating their children and made all of us, including the child I saw on rounds, more susceptible to infection with these bacteria. Last year, Julia Joffe wrote an incisive and frightening piece in The New Republic about this issue. She explains the gravity of the problem:
Vaccinations work by creating something called herd immunity: When most of a population is immunized against a disease, it protects even those in it who are not vaccinated, either because they are pregnant or babies or old or sick. For herd immunity to work, 95 percent of the population needs to be immunized. But the anti-vaccinators have done a good job undermining it. In 2010, for example, only 91 percent of California kindergarteners were up to date on their shots. Unsurprisingly, California had a massive pertussis outbreak.... 
From 2011 to 2012, reported pertussis incidences rose more than threefold in 21 states. (And that’s just reported cases. Since we’re not primed to be on the look-out for it, many people may simply not realize they have it.) In 2012, the CDC said that the number of pertussis cases was higher than at any point in 50 years. That year, Washington state declared an epidemic; this year, Texas did, too. Washington, D.C. has also seen a dramatic increase. This fall, Cincinnati reported a 283 percent increase in pertussis.... 
A study recently published in the journal Pediatrics indicated that outbreaks of these antediluvian diseases clustered where parents filed non-medical exemptions — that is, where parents decided not to vaccinate their kids because of their personal beliefs. The study found that areas with high concentrations of conscientious objectors were 2.5 times more likely to have an outbreak of pertussis.
But these “personal beliefs” are not part of some novel and modern ideological movement. In fact, the arguments of the anti-vaccination movement of today closely resemble those perpetuated when Europe first used vaccines in the 18th century. And when we consider the six-month-old in the hospital and our current predicament outlined by Julia Joffe, this fact should give us hope.

The Chinese first used vaccines, inhaling powder from smallpox scabs on deceased patients, a method which eventually moved west to Britain during the 18th century — the British rubbed scabs of smallpox victims into newly created scratches on their skin. And most of the time this worked, even if there were risks involved. In fact, as Dr. William R. Clark, a former Professor of Immunology at UCLA, writes in his book on the immune system, At War Within, even in that era, “from a public health point of view, inoculation made great sense.” Nonetheless, many physicians and religious leaders at the time opposed this method of preventive care for a few different reasons.

First, religious leaders spoke out against vaccination because they thought it interfered with God’s plan. In July 1722, Reverend Edmund Massey argued in St. Andrew’s Church that humans were punished for their sins with illness, and that attempting to prevent these diseases with vaccines was a “diabolical operation.”

But that wasn’t all. According to some, the government and the wealthy used vaccines to subject, or profit from, the populace. As Clark recounts in his book, William Wagstaffe, a physician at the time, wrote the following about Britain’s female ruling class, which first began to use the vaccines:

Posterity perhaps will scarcely be brought to believe, that an Experiment practiced only by a few Ignorant Women, amongst an illiterate and unthinking People, shou’d on a sudden, and upon a slender Experience, so far obtain in one of the Politest Nations in the World, as to be receiv’d into the Royal Palace.

In other words, ignorant leaders practicing inoculation took advantage of the ignorant citizens. J. M. Peebles, an American physician, wrote a book in 1900 entitled Vaccination: A Curse and a Menace to Personal Liberty, with Statistics Showing its Dangers and Criminality. In it, he explained, “The vaccination practice…has not only become the chief menace and gravest danger to the health of the rising generation, but likewise the crowning outrage upon the personal liberty of the American system.” Further, the “vaccination syndicate” is “continually lobbying our legislatures for an extension of privileges on the pretense that the public welfare will thereby be enhanced.” So, the pro-vaccine “syndicate,” using the American government, forces its mendacious ideas upon American citizens.

And the harmful medical effects of the inoculations bothered scientists at the time who, according to Dr. Clark, “were concerned about the risk, and not completely convinced that the protection was genuine or long lasting.” Peebles covered the vaccine’s deleterious effects in his book, too. The “vaccine-poison,” he asserted, will take its time in killing its victim or do little to prevent death, “one year, ten years, this generation or the next; no matter, death has a mortgage on the premises and will claim his own and receive it on demand.”

These objections sound entirely familiar. Dr. Suzanne Humphries, a nephrologist and homeopath, has recently rewritten the religious argument for the International Medical Council on Vaccination: “Vaccines are the template for the fear-based belief system that those who don’t know their history will easily fall for. The trajectory of fear removes God from the picture. A fear-ridden populace couldn’t possibly credit God with any usefulness once the medical/pharmaceutical industry sets itself up in God’s place.” This claim echoes Reverend Massey.

Professor Daniel A. Salmon, of the Johns Hopkins School of Public Health, quoted in a New York Times article, discusses many of the groups who refuse to vaccinate their children. He explains that some oppose vaccines because they distrust the government or believe that government is in bed with the big pharma vaccine industry. Moreover, in an editorial post on the Alliance For Natural Health website, the group claims that the “cozy relationship of government with the drug companies may be why the CDC is now recommending a cocktail of over ten different vaccines.” William Wagstaffe or J. M. Peebles could have written this.

And, of course, detractors argue that the side effects of the vaccines are too dangerous and may even cause autism. Jenny McCarthy, in a similar vein as J. M. Peebles, made this argument. (She recently attempted to paint herself as “pro-vaccine,” which is simply not true.)

But why should we be comforted by this current of familiar anti-vaccination arguments? Because despite the historical resistance to the smallpox vaccination, eventually the vaccine was successful — so successful, in fact, that the World Health Assembly declared smallpox eradicated in 1980. Therefore, the vaccine movement has won out in the past against similar arguments and can do so again. Will whooping cough be eradicated with successful vaccination? I can’t say, but even a minute sway in opinion can make the difference between herd immunity and an epidemic. And that would decrease the number of six-month-olds and their parents who must suffer in anguish through those frightening moments on the precipice of breathlessness.

4 comments:

  • An important piece on the efficacy of vaccines and the importance of not discarding worthwhile scientific achievements. May no herd remain immune to the good sense of Aaron Rothstein.

  • I have to ask, since you're commenting on this post about vaccines: were you named (or did you choose the Internet pseudonym) Jenner after Edward Jenner?

  • Adam, good catch. I was named after Edward Jenner. Given my stance on this topic, I would have done well to disclose my conflict of interest.

  • Childhood illnesses were one of God's creations. We do our best to provide a good environment so our children will be healthy. If they get sick, it is wonderful to have medical treatments, and if a child dies, he died a natural death. If, on the other hand, we vaccinate a healthy child knowing that there is a risk however small and that child dies, we are guilty of murder. God did not make a mistake when he created us or disease. We make a mistake when we try to play God.

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