Anxiety about autism may be partly behind California outbreak

Unvaccinated babies also dying because teens and adults don’t get re-immunized

The video clip is just 11 seconds long. But who would want to watch any more than that—of a baby gasping for air between coughs so wrenching he can’t even cry?

Whooping cough, or pertussis, can kill an infant. So far, nine have died in California this year in what has been called the state’s “worst outbreak” in a half-century. The introduction of the first vaccine against the disease decades ago dramatically reduced the number of cases in the United States by 1980.

Medical experts say one factor in the return of pertussis is the increasing number of parents in California who refuse to inoculate their newborns because they hear claims by neighbors, relatives and a certain celebrity mom that vaccines can lead to autism.

A growing body of scientific evidence shows this not to be the case. Nonetheless, all the parental anxiety about vaccines underscores the ethical dilemma society faces when public health imperatives clash with individual freedoms. In this instance, should schools and states require that all infants be vaccinated, against the wishes of parents who hold certain beliefs?

Margaret Moon, a pediatrician and core faculty member at the Johns Hopkins Institute of Bioethics, sympathizes with the struggles of anxious parents and knows that their concerns are sincere. But she emphasizes that more needs to be done to “strengthen the therapeutic alliance.” This means working with families to help them understand the risks and benefits—although Moon notes that the pertussis vaccine has been scientifically shown to be one of medicine’s safest.

“To force parents to bring their babies in for vaccinations, when they’re really anxious about it, seems completely counterproductive,” Moon says. “But in the meantime, we’re leaving kids at risk.”

Blanket fears about vaccines

Much of the lingering public anxiety revolves around thimerosal, a mercury-containing preservative once common in vaccines. It was believed—and still is by some parents and skeptics—that the cumulative effect of the various vaccinations recommended for infants would be toxic and retard their developing nervous system.

According to the Centers for Disease Control and Prevention, “there is no convincing evidence” that low doses of thimerosal in vaccines can cause harm. Perhaps, more the point, the American Academy of Pediatrics, vaccine makers and the CDC’s Public Health Service division agreed in 1999 that the preservative should be reduced or eliminated in vaccines as a precaution.

Since 2001, vaccines routinely recommended for children have been free of thimerosal—with the exception of some influenza vaccines. In addition, the pertussis vaccine in particular had already been made much safer a decade earlier, when an acellular formulation of it was introduced. Without any biological remnant of the virus that causes pertussis in the vaccine, the chance of developing symptoms dropped significantly.

The CDC has been steadfast in issuing public announcements about these advances. But to the average parent, a former Playboy model who gets on television and online and accuses vaccines of causing her young son’s autism can be equally compelling—if not more so.

According to faculty at the Berman Institute, the CDC and the pediatrics academy could have been swifter about acknowledging the growing disconnect between the science, the facts and the “pop” treatment of the subject.  They could have listened more to parents and taken steps to initiate a dialogue. Public health authorities were also slow to refute the accusations with facts, and explain the science in a way that anyone could understand.

That might have gotten into the confusing terrain of communicating biostatistics, but the effort was nonetheless needed.

“The average citizen listens to and is persuaded by very simple messages that confirm their underlying fears,” says Peter Terry, another physician on faculty at the Berman Institute. “Public health organizations don’t counter misinformation as quickly and vociferously as they ought to.”

Added Moon: “We get on our high horse when people say they’re worried about vaccines, instead of using that moment as an opportunity to strengthen the therapeutic alliance.”

Restoring faith and herd immunity

That scenario is changing. The October issue of Pediatrics features a study by CDC researchers showing that infants exposed to the highest levels of thimerosal are no more likely to develop autism than those exposed to low levels of the preservative. And within the last few years, health organizations have themselves turned to Hollywood to develop messages with comparable star power.

For instance, the March of Dimes and the vaccine maker Sanofi Pasteur have teamed up to produce videos featuring singer-actress Jennifer Lopez and NASCAR’s Jeff Gordon, which warn parents that whooping cough is on the rise and urge adults to get immunized.

The childhood vaccine is delivered as part of the combined diphtheria, tetanus and acellular pertussis (DTaP) vaccine, which the CDC recommends be given at two, four and six months. The CDC then recommends revaccination again sometime between 14 and 18 months, and once more between the ages of 4 and 6 years.

Because immunity wanes, adolescents and adults should get a booster shot every 10 years. But that fact is only now being communicated as a formal recommendation; and thus far, it has taken a backseat to the public health campaign’s current focus on getting infants vaccinated. And as pertussis seemed headed toward annihilation around the country, the message that all age groups stay immunized faded.

Whooping cough reached national attention in the 1920s, with reports peaking at about 265,000 cases and 7,500 deaths in 1934. Then, starting in the late 1940s, when the first vaccine against pertussis began to be widely used, the rate of infection in America dropped steadily and dramatically.

By 1980, the annual number of cases dropped to 1,730 nationwide—a 99 percent decrease in incidence since the disease’s discovery. In other words, while news stories have stated that whooping cough was once wiped out, that was never the case.

“Certainly, a horrible illness was reduced tremendously,” Moon says. “But because immunization has never been life long, it’s really going to be hard to completely eradicate it.”

The Sept. 7 article in the Los Angeles Times that reported on the string of infant deaths also stated that California is seeing the highest number of cases of pertussis since 1958—with 3,600 reported this year. A Sept. 24 article in the New York Times said public health authorities estimate that only half of all adults in the United States have gotten pertussis booster shots as recommended.

Misplaced vaccine anxiety may be the most publicized factor in the rise of pertussis rates in California and other states where “personal-belief exemptions” allow parents to send their kids to school unimmunized. But another reason, as one study shows, is that unprotected teens and adults are catching the disease and infecting infants at home.

“Adults don’t get very sick with pertussis. For them, it’s a bad cold,” Moon says. “For babies, it can be life threatening.”

Moon and Terry call for a two-pronged approach: continued focus on immunizing infants, but intensification of the message that it is just as essential for adolescents and adults to stay on top of vaccinations. And because teens and grownups are notoriously bad about coming to a clinic just for a shot, Terry suggests combining the adult pertussis vaccine with the booster for tetanus.

He and Moon also agree that parents who refuse to immunize their infant based on non-medical beliefs ought to be held responsible for protecting their baby by immunizing themselves.

“There’s no evidence that vaccinations harm adolescents or adults,” Terry says. “If you’re not willing to vaccinate your newborn, will you at least get yourself vaccinated?”

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Margaret Moon
Michael Pena
Peter Terry

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