The Persistent Threat of Vaccine-Preventable Diseases

Public health experts are tracking resurgent viruses and bacteria, underscoring the importance of immunization.

A hundred years ago, the 1918 flu pandemic killed an estimated 20 million to 40 million people worldwide. And just 50 years ago, cases of whooping cough, polio, measles, mumps and other diseases were widely prevalent.

But as infection rates have dropped, “so has the memory of the devastating consequences that diseases such as measles, pertussis, diphtheria and the flu can have,” says Dr. Damon Arnold, medical director for Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas. “We’ve lost the memory of the suffering people endured from diseases that are now preventable if people would only get immunized.”

A number of contagious diseases thought to have been eradicated or contained in the United States appear to be making a comeback. Public health experts are tracking resurgent viruses and bacteria such as measles, mumps, whooping cough and more.

More than 71,550 cases of whooping cough, for example, have been diagnosed in North America over a nine-year span since 2008, with nearly 22,650 of the cases reported in 2013 alone, according to the Council on Foreign Relations’ online disease tracker, VaccinesWork.org. The disease tracker also shows about 15,000 cases of mumps were reported in North America during the same span.

“The United States has done an excellent job of promoting immunization, which has helped keep the spread of vaccine-preventable disease in check,” Dr. Arnold says. Immunization-awareness campaigns have achieved a vaccination rate of 90 percent or above for the most common infectious diseases. Still, the rising incidence of preventable contagious diseases in the U.S. is surprising. Experts cite global travel, refusal to vaccinate, under-vaccination, waning immunity and less-effective vaccines.

Measles outbreaks

The World Health Organization identifies 26 dangerous diseases that can be prevented with vaccines. One of the most contagious is measles, and the sudden reemergence of the virus has prompted public health officials to renew warnings.

Nearly 670 cases of measles in 27 states were reported in 2014, the greatest outbreak of the disease since the CDC declared it eliminated in 2000. Outbreaks have occurred every year since, with nearly 120 people in 15 states contracting the disease in the first nine months of 2017.

Measles can spread quickly. One of the most publicized outbreaks occurred during a short span at an amusement park in California in late 2014 to early 2015. The CDC said the outbreak likely started from an infected overseas visitor and eventually infected 125 people. All those infected had the virus genotype seen in large prior outbreaks overseas.

More recently, the Minnesota Department of Health witnessed a rash of measles cases starting in April 2017. In less than two months, the health department confirmed 65 cases, with thousands more likely unreported. Although three of the infected had received two doses of vaccine before the outbreak, the rest were identified as unvaccinated, the CDC said.

Despite the spike in cases, the overall incidence of measles in the United States remains at less than one case per million people. That’s low compared with the worldwide rate of 40 cases per million, but global trade and travel serve as conduits for the spread of contagious diseases. The virus types found in several of our domestic measles outbreaks since 2009 have mirrored ones fueling outbreaks overseas, the CDC reports.

Although vaccination is strongly recommended, it’s not a guarantee that a person is immune from an infection. Giving two doses of the mumps vaccine, which is administered along with the measles and rubella vaccines (MMR), is found to be 88 percent effective in protecting against infection. In recent years, mumps outbreaks have occurred in schools, colleges and camps nationwide, with more than 4,400 cases reported through the first nine months of 2017.

The intersection of health and poverty

The CDC estimates that vaccination will prevent about 322 million illnesses, 21 million hospitalizations and 732,000 deaths over the lifetimes of children born between 1994 and 2013.

But the benefits won’t be distributed evenly across the population. Vaccination efforts still fall short among one of the most vulnerable segments of society — the urban poor.

The CDC and independent researchers have found that families living below the national poverty level consistently report less vaccination coverage than families living at or above the poverty level.

“Socioeconomic status is the most powerful predictor of disease, disorder, injury and mortality we have,” says Dr. Tom Boyce, chief of the University of California San Francisco’s Division of Developmental Medicine. Experts say poor Americans face a number of hurdles to getting immunized, including lacking the transportation or time to get children to a doctor’s office.

Tasked with helping local, state and federal authorities improve community health, the Community Preventive Services Task Force found in 2016 that home visits by nurses or health workers—although costly—could be very effective in getting more urban poor vaccinated.

Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas utilize mobile immunization programs to offer free vaccines to children. Their “care vans” visit schools, churches and community centers in lower income neighborhoods to reach families that may have few other options.

Under the Affordable Care Act, health plans pay for common vaccinations with no out-of-pocket costs for members.

Childhood vaccination is considered one of the top public health accomplishments of the 20th Century. A new report by the Blue Cross and Blue Shield Association found that 77 percent of commercially insured children born in 2013 completed the seven CDC-recommended vaccinations by 2016, up from 69 percent of children born in 2010 who completed them by 2013.

But the report also found wide geographic variation in completion rate – from a high of 86 percent in North Dakota to a low of 63 percent in Nevada. Also, the rate of parents refusing one or more of the vaccinations for their children increased nearly 70 percent – 4.2 percent versus 2.5 percent – for children born in 2013 compared with those born in 2014.

 

 

Calling the shots

Another obstacle to immunization has been the fear engendered by discredited internet stories and faulty studies that question the effectiveness and safety of vaccines.

Those who choose not to vaccinate may be playing a dangerous game of wait-and-see, Arnold says.

“During the 1990s I assisted an orthopedic surgery doctor in the polio wards of Uganda,” Arnold says. “The affected kids were suffering major health issues and deformities and sometimes faced death as a result of not having been immunized. The consequences were astounding.” The patients and their families would gladly have immunized against the disease, he says, if only the vaccine had been made available to them – “something we take for granted.”

Public health issues sometimes pit an individual’s religious and philosophical freedom against the broader public good. Arguments about vaccines are often reduced to compulsory vaccination versus an individual’s right to choose.

But it doesn’t have to be that way, says Dr. J.W. Hendricks, a pediatrician with 30 years of practice and co-author of several U.S. academic studies on immunization. One of the studies focused on physicians refusing to serve families who choose not to vaccinate.

“I never quite understood their position,” Hendricks said of the physicians. “Having a relationship with a patient gives you the opportunity to revisit the issue. Ending the relationship removes that opportunity.”

Hendricks believes the better answer is to educate the public to make informed choices. A little misinformation can cause incalculable harm. It took the medical community 10 years, he says, to refute a British physician who falsified data in a study linking autism to childhood measles, mumps and rubella vaccines. He says he wonders how many children needlessly suffered with the diseases during that time.

“Choice needs to be part of the equation, albeit informed choice,” says Hendricks, who now oversees a team of medical directors with the five Blue Cross and Blue Shield Plans. “Parents who choose not to vaccinate need to be reminded of the risks their children face. Ultimately, though, the decision should rest with them.”

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