Worth a Shot

As vaccination rates drop, once-rare diseases like whooping cough and measles come roaring back.
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The drive from Midland to Lubbock is just shy of two hours, but last summer it felt like the longest drive Mindy Syler Hale and her husband, Brandon, had ever taken. The whoop-whoop of helicopter blades sliced through the sky above as they set off. The couple’s 2-week-old son, Brooks, was in that helicopter, hooked up to a continuous positive airway pressure (CPAP) machine enabling him to breathe. There was no room for Mindy or Brandon inside the helicopter. “Watching an infant go on board without you—it’s hard,” Mindy says. “The only thing we could do at that point was pray.”

Brooks Hale was born on July 16, 2013. Nine days later, he developed a small cough, but his pediatrician told Mindy he was fine, and he was sent home. A week later, while Mindy was burping him, Brooks stopped breathing. “He turned blue,” she recalls. “And we rushed him to the ER.” There, the doctor ordered X-rays and found a spot on the little boy’s lung. They thought it might be pneumonia and transferred him to a hospital in Midland. Then things got worse. In Midland, Brooks stopped breathing and turned ashy gray. It took doctors a minute and a half to get him breathing on his own again, Mindy says. That’s when doctors decided to Life-Flight him to Lubbock.

The Hales live in Westbrook, a small farming community about an hour west of Abilene. Brandon works in the oil fields, and Mindy is a stay-at-home mom, looking after Brooks and his 4-year-old brother, Brennand. Brandon also happens to be chief of the local volunteer firefighters, and Mindy is a member of the organization. The couple had seen people Life-Flighted to the hospital before, but never like this, never their own child. “I was a basket case,” Mindy says. “I cried from Midland to Lubbock. My husband never cries, and he was the same way. We felt like we were going to lose this baby.”

When Mindy and Brandon arrived in Lubbock, their son was lying on a gurney, intubated, with an oxygen mask on. “He was still breathing,” Mindy says, “but he was getting worse. To watch your child turn ashy gray was the scariest thing that had ever happened.”

Brooks stayed in the pediatric intensive care unit in Lubbock for three days. He was given antibiotics and oxygen, and then, slowly, he began to get better. The diagnosis was pertussis, or whooping cough, an infection of the respiratory tract. It initially resembles a fairly minor cold—runny eyes, cough—but can quickly become life-threatening, especially in babies. Children younger than 6 months are much more susceptible because their airways are so small, and because the first vaccines for pertussis aren’t given until 2 months. And because the initial symptoms seem so benign, parents often don’t think it’s worth a doctor’s visit. Over a period of two or three weeks, though, that cough becomes more severe. A person with pertussis struggles for breath, resulting in the “whooping” sound. According to the Centers for Disease Control (CDC), 255 people died from whooping cough in the United States between 2000 and 2010; 228 of them were less than 6 months old.

More than half the infants younger than a year who get pertussis must be hospitalized, according to the Texas Department of State Health Services. Half will have apnea (either their respiration will slow or they’ll stop breathing altogether). One in five will get pneumonia. One in 300 will develop encephalopathy, a brain disease, and one in 100 will die.

Brooks Hale was one of the 3,621 cases of pertussis in Texas in 2013—the majority in the north and west of the state—and 804 (22 percent) of them were children younger than 1. Of the 3,621 cases, more than 400 people were hospitalized, and five children died. It was the largest outbreak in Texas since the 1950s. Pertussis, like measles and other diseases that vaccines nearly eradicated, is once again a major public health threat. The question is why.

 

Vaccination campaigns all but eradicated troublesome diseases like polio and whooping cough. Leggett Memorial Hospital employees hold a banner announcing the arrival of the polio vaccine in Cleveland, Texas, 1962.
Vaccination campaigns all but eradicated troublesome diseases like polio and whooping cough. Leggett Memorial Hospital employees hold a banner announcing the arrival of the polio vaccine in Cleveland, Texas, 1962.

Ninety years ago, pertussis infected 250,000 Americans and killed up to 9,000 every year. In the 1940s, when a pertussis vaccine became available, the number of cases began to decline, and by the mid-1970s the disease had been all but eradicated, with little more than 1,000 people infected per year nationwide. From then on, though, public health officials have seen an upward trend: 18,719 cases in 2011, and then a huge jump to 48,277 cases nationally in 2012.

There are several reasons for the spike in pertussis cases, but doctors and public health officials pinpoint one disturbing cause: fewer people vaccinated. Dr. Steven Novella, a doctor at Yale University writing on the Science-Based Medicine blog, said there are serious concerns among public health doctors “about vaccine refusal as a contributor to the resurgence of whooping cough.”

A 2010 outbreak of the disease in California infected 9,120 people and killed 10. A subsequent study published in Pediatrics Journal found that people living in areas of the state where parents had opted out of vaccinating their children for personal reasons were 2.5 times more likely to live in an area with a large number of pertussis cases.

As Dr. Paul Offit, chief of the Division of Infectious Diseases at The Children’s Hospital of Philadelphia, wrote on the CDC website: “In communities with clusters of under-immunized children, the incidence of vaccine-preventable diseases has risen. More measles outbreaks occurred in the United States in 2011 than in any year since 1996, primarily due to the increase in imported measles cases. Pertussis outbreaks have swept the nation … type b meningitis has claimed the lives of several children in Minnesota and Pennsylvania, deaths that could have easily been avoided if parents had not feared vaccines more than the diseases they prevent.”

Pertussis, measles and other preventable diseases nearly disappeared in the United States thanks to what’s known as herd immunity. Herd immunity occurs when enough of the population is vaccinated against a disease that it can’t spread and cause an epidemic. Herd immunity protects even people who aren’t vaccinated, because everyone else around them is inoculated. But Dr. Novella says that thanks to the anti-vaccine movement, there’s an unsubstantiated fear about the safety of vaccines—including the vaccines against pertussis and measles—and that refusing them can result in a loss of this herd immunity. The threshold for herd immunity varies depending on the disease. For mumps, it’s vaccination of anywhere between 75 and 86 percent of the population. For Rubella it’s 80 to 85 percent. For pertussis, it’s 92 to 94 percent.

U.S. vaccination rates for pertussis are falling below that level. In 2012, just 91.9 percent of kids younger than 3 years old received the pertussis vaccine, according to CDC survey data. In older children, the coverage was even lower. Only 83 percent of children ages 10-12 were inoculated against pertussis in 2012.

Writing in Contemporary Pediatrics magazine, David Ropeik, an expert in risk who teaches at Harvard University, puts it like this: “We pass laws, or impose economic rules, or find other ways to discourage individual behaviors that threaten the greater common good. You don’t get to drive drunk. You don’t get to smoke in public places. … What should we do about people who decline vaccination for themselves or their children and put the greater public at risk by fueling the resurgence of nearly eradicated diseases? Isn’t this the same thing? … Of course it is.”

Vaccine opponents (so-called anti-vaxers) are a very vocal minority, and they’ve found some spurious celebrity endorsements that ensure their message is amplified. Essentially they all have one thing in common: a belief that the side effects of vaccines are often worse than the diseases they’re trying to prevent. The problem? There isn’t a shred of evidence to back up this belief, but it manages to play on our wider distrust of government and fear that health authorities must be colluding with vaccine manufacturers.

The number of pertussis outbreaks in Texas in 2013 was the highest since 1959, when there were 5,842 cases. The state’s health department collates reports through March of 2014, so the final tally of 2013 cases could be even higher.

According to Tod Merkel, a microbiologist in the FDA’s Office of Vaccines Research and Review, the disease can be treated by antibiotics, but they’re often given too late, and children who have caught the bacterial infection often exhibit severe symptoms before they start getting better. “There’s a point of no return,” Merkel says.

Pertussis rates in the U.S. as a whole reached a 50-year high of 42,000 cases in 2012. So the FDA decided to launch a study to find out what was going on. What was interesting was that unlike the California outbreak, blame for the nationwide rise in pertussis couldn’t be placed solely on anti-vaxers. Merkel was one of the authors of the FDA study that found that the current vaccine, introduced in the 1990s, doesn’t adequately prevent colonization or transmission of the disease, and they recommended developing an improved vaccine.

It wasn’t always this way. Before the 1990s, we used what was known as a whole-cell pertussis vaccine—bacterial cells of the disease itself that had been killed. But there were side effects: swelling, fever, drowsiness, even convulsions. So scientists developed an acellular vaccine, which uses fragments of bacterial cells. Side effects were rare. The problem was, it wasn’t nearly as effective, and immunity wore off after five years.

The waning effectiveness of the pertussis vaccine likely partially explains why the rates of the disease were so high in Texas in 2013. Parents refusing to vaccinate their children certainly exacerbated the problem, but so did putting them on a “slow schedule” in which parents delay certain vaccinations because of an erroneous and completely unscientific view that too many vaccines can overwhelm the immune system. And so did simply forgetting to get a booster.

Chris Van Deusen, with the Texas Department of State Health Services, says the reasons for the outbreak here are varied: Like so many infectious diseases, pertussis is cyclical; immunity wears off; and there’s more awareness by physicians and therefore a greater chance of diagnosis.

2-week-old Brooks Hale in the hospital with whooping cough.
2-week-old Brooks Hale in the hospital with whooping cough.

The Hales’ son Brooks was too young to be given the pertussis vaccine. Mindy received it the day after he was born, but her husband Brandon didn’t. At the hospital in Lubbock, the little boy was put on a course of antibiotics and monitored. “The drugs helped,” Mindy says, “but it had to run its course.”

Brooks pulled through. Five months on, he was sitting up and attempting to crawl. “When he coughs now, it scares everybody else but I think that’s nothing,” Mindy told me in December. “A week ago he slept all night and didn’t cough once, and it was such a huge thing. You’d never know he was a sick baby [who had been] hooked up to that machine.”

Dr. Don Murphey, medical director of the pediatric infectious diseases center at Cook Children’s Medical Center in Fort Worth, says that as a result of the FDA study, the medical profession is changing its strategy for dealing with pertussis. We’ve known for a long time that though adults rarely exhibit serious symptoms (maybe a little prolonged cough), they can still spread the infection. But public-health officials thought the “Tdap” combined vaccine (tetanus, diphtheria, pertussis) for adults would cause a drop in the number of people with whooping cough. That wasn’t the case.

“We thought the solution was to immunize every adult in the U.S., but that’s a very difficult thing to do,” Dr. Murphey says, sitting in his Fort Worth office. “Even if you go on the news, and you put out banners and emails and everything, it is nigh on impossible to do anything with every adult in the U.S.”

So there was a problem: Kids under 2 months old weren’t immune, and adults weren’t getting immunized, meaning they could easily pass on the infection to the most vulnerable members of society. “And it really wasn’t until about a year ago that we started having our suspicions about the current vaccine schedule,” Dr. Murphey says, “because what we started to see was more and more pertussis. It was re-emerging.”

Mothers pass on some antibodies to their offspring, but evidently not enough. Children would begin to get their schedule of shots at 2 months, but according to Dr. Murphey they don’t build up good protection until they are about 6 months old. “So,” he says, “you have the most susceptible kids with the least amount of protection.”

Public-health officials concluded the answer was to immunize pregnant women. “They will then make the antibody, and it doesn’t have to last for a long time,” Dr. Murphey explains. “It will transfer to the baby, those babies will then be protected, and it will help prevent these babies from being injured or dying.”

But some people are reluctant to get vaccinated during pregnancy. “I think the ethics of anxiety about unsafe vaccines is difficult,” Dr. Murphey says, “because we have families that want to do the best thing for their children and they are unwilling to take any risk, but they are willing to risk public health.  I think if you asked a philosopher or an ethicist if that is okay, they would say no.”

The problem, Dr. Murphey says, is that parents look on the Internet, and in that world of free and limitless speech, you can always find “evidence” to support a notion that something is dangerous. Add a celebrity endorsement or two and erroneous views about vaccines quickly go viral and become ever more seductive.

“I remember when Jenny McCarthy was on Larry King, together with three pediatricians—one was the head of the American Association of Pediatricians and one was from the National Children’s Medical Center in Washington, D.C.,” Dr. Murphey says. “Jenny McCarthy got two-thirds of the air time and all of the emotional intensity and then … the guys would start to talk in a scientific, reasonable, rational way, but that’s just not exciting. Public health is not exciting.”

But heeding the words of vaccine skeptics over medical professionals can be deadly, as has happened with the measles epidemic.

 

In August 2013, health officials in Texas identified a church north of Dallas that was at the heart of an outbreak of the measles virus in which 25 people became infected. A visitor to the Eagle Mountain International Church in Newark, whose senior pastor Terri Pearsons is the daughter of televangelist Kenneth Copeland, had become exposed to the disease while on a mission trip to Indonesia. Pearsons had been critical of measles vaccinations, and it turned out that the majority of her congregation hadn’t been immunized and quickly contracted the disease.

Measles is one of the most communicable of all infectious diseases and at one time killed between 3,000 and 5,000 Americans every year. It’s transmitted through breathing, coughing and sneezing, and begins with a fever, cough and cold-like symptoms such as a runny nose and watery eyes. A rash usually develops a few days later, and for most people it gets better by itself. But six in 100 people develop pneumonia. One in 1,000 gets encephalitis, a serious brain infection. Pregnant women who contract measles can miscarry. Today, about two in every 1,000 people die. Fortunately, the measles, mumps and rubella (MMR) vaccination had made measles a rare affliction.

But in 2011, the U.S. saw the biggest outbreak of measles in more than 15 years. The CDC reported 222 cases, more than four times the average annual rate. Last year there were 175 cases—still way above normal, and which the CDC attributed to both infected travelers catching the disease abroad and spreading it to unvaccinated children and adults. According to CDC Director Dr. Thomas Frieden, about 90 percent of the people who caught measles in 2013 were not vaccinated “either because they refused or were not vaccinated on time.”

One of the reasons for parents’ refusal to let their children have the MMR vaccination is the thoroughly debunked belief that it can cause autism. This stems from a now discredited 1998 paper published in the British medical journal The Lancet, which suggested that the vaccine could cause a series of problems, including intestinal inflammation, that could result in the development of autism. The subsequent publicity surrounding the paper caused panic among parents, a drop in vaccine rates and a rise in measles.

At a lengthy hearing, the General Medical Council, the body that maintains the official register of medical doctors in the U.K., found the author of the paper, Andrew Wakefield, guilty of serious professional misconduct and struck him from its roster. Since then the Institute of Medicine of the United States National Academies, the Centers for Disease Control and Prevention, and the U.K.’s National Health Service have all found no link between MMR and autism (see “Autism Inc.,” February 2013).

Dr. Murphey at the Cook Children’s Medical Center says there’s also a worrying trend toward delaying immunizations, based on “the belief that maybe kids are getting too many immunizations too quickly and that’s causing some sort of issue with the immune system, with their development, so it’s better to slow down [the vaccination schedule].”

He says pediatricians are frustrated with parents who say they’ve researched the issue on the Internet and want to delay vaccination. “For measles and whooping cough, if you slow down protection, you expand the time when those kids are susceptible and then you threaten public health,” Dr. Murphey says. “Then you will have more outbreaks, so it’s really a bad idea.” The fact is, he says, “There is no evidence whatsoever that it overloads the immune system.”

It’s the same problem with some attitudes toward the flu vaccine: It’s just flu. I’ve had flu. Why would anyone want to get immunized? The short answer, Dr. Murphey says, is that if you get immunized you’re not going to be one of those people hooked up to a ventilator in the ICU. “If somebody says flu is not dangerous, I would say, you know what, in 2009 with the H1N1 epidemic, we had four kids on ECMO [a machine giving respiratory and cardiac support] in the ICU at one time and that never happens. Out of 1,000 people who contract the flu, a couple of them are going to get pneumonia and that’s a bad problem; it’s a bad disease, even when you use anti-virals and supportive care. It can shut down your lungs, and we do not live long with shut-down lungs.”

Similarly, Dr. Murphey says, pertussis can cause patients to suffer respiratory failure. “It affects the heart, it affects the airways, it affects the vessels, and when that’s going on it also affects the brain, and so you can get neurologic problems.”

As for Mindy Syler Hale and her husband Brandon, they’ve started urging all their friends and family to receive the Tdap vaccination. What happened to Brooks, she says, put everything in perspective. “Think how you’d feel sitting there and looking at your child go through what we went through. Think about having to put your child on that helicopter and not knowing whether when you got to the hospital, he’d be alive. Even our pediatrician didn’t know if he’d survive the flight.”

Mindy now wonders if Brooks would have had more antibodies in his system, more immunity, if she’d been vaccinated during her pregnancy. “He might still have caught whooping cough,” she says, “but it would have given him more of a fighting chance.”

If that were the case—or if Brooks’ father, Brandon, had been vaccinated against the disease—maybe Brooks would have avoided the Life-Flight to Lubbock. Maybe Mindy and Brandon wouldn’t have had that heartbreaking two-hour drive. Maybe they wouldn’t have had to look at him lying on a gurney, wearing an oxygen mask.

“It makes you wonder,” Mindy says. “Whether we’d have gone through everything we went through.” And yet Brooks survived. Despite everything that happened, he was one of the lucky ones.