Measles: Still "A Thing" (in the US in 2016)

Buried amongst the myriad Zika virus headlines, so hard to find it took some looking, is news of measles cases in the US...again. While not as explosive as the recent Disneyland-linked outbreak the 2 cases that have occurred this year are instructive as they are cases that should not be occurring in the US.

The cases occurred in the states of California and Texas. In Texas, an unvaccinated child who traveled internationally -- where measles is rampant -- was infected and later exposed classmates at an elementary school early in January. That this happened in Texas is not surprising as it is the 2nd least vaccinated state and this low rate of vaccination is reflected in the fact that some of the students exposed were not vaccinated. It appears, however, that herd immunity as well as luck delimited the impact of this case as no secondary cases occurred and the incubation period has since passed.

California, where the other 2016 case occurred, is the state in which a new law was enacted to increase the rates of vaccination in schools by eliminating religious and "philosophical" exemptions. California, being the epicenter of the 2014-2015 outbreak, also had a major reminder of the danger of measles that had ripple effects that led to increased vaccine confidence among the vaccine-hesitant. The details of the California case haven't been released and it will be important to determine the circumstances surrounding this case.

More measles cases will occur in the US this year and many children will remain unvaccinated kindling for this virus.

Vaccine Efficacy: A Fact, Not Just Something to Believe In

As I like to keep my hand slightly in emergency medicine yesterday I worked one of my (infrequent) shifts in the emergency department of my hometown hospital. Throughout the course of the shift at this medium-sized community hospital, I took care of several cases of pneumonia and likely influenza.

One patient encounter particularly struck me. I took care of a girl of about 6 years of age who had upper respiratory complaints such as cough, sore throat, and fever. I make a point of asking every parent of a child with a potential infectious disease the vaccination status of the child because it is an important piece of information to know for diagnostic purposes and, if found to be lacking, an important opportunity for education. This particular child was fully vaccinated except against influenza. The mother stated "we don't believe in flu shots." Her reason was that the shots, she alleged, make her entire family sick immediately upon receipt. I tried to debunk this "belief" but really didn't get anywhere. I left the room and went back to the nurse's station and vented to the nurse who said she didn't "believe" in flu shots either!

I find the nurse's position really untenable as she is well educated on the efficacy of vaccines and the role they play in controlling infectious diseases and preventing the worst complications of infections such as influenza. This is something taught in nursing schools and written about in nursing journals; it is a well established part of nursing practice. I suppose this nurse is someone that will unfortunately prove recalcitrant to any mandatory influenza vaccine campaign which the major academic medical center for whom I primarily work introduced this year.

What I think is interesting is both the mother and the nurse used the concept of "belief" when it came to the efficacy influenza vaccine. The definition of belief is "a state or habit of mind in which trust or confidence is placed in some person or thing" and I do have confidence and trust in the influenza vaccine but I would never put it that way. The efficacy of a vaccine, about 60% (which could be much better) in the case of the flu vaccine, is an established fact dependent only on the immunological phenomenon elicted by the vaccine. The immunological effects of the vaccine occurs whether someone "believes" in it or not. In other words, it is a fact independent of anyone's recognition of it. 

A fact can be evaded, but it will still be a fact. Reality has primacy and vaccines work.

Chickenpox Party in the Royals Dugout

If I ever walk through a baseball dugout, my biggest worry would be stepping in or touching chewing tobacco spit however the Kansas City Royals have much more to worry about after 2 players contracted chickenpox. It is assumed that the 2 infected players were not vaccinated and somehow escaped natural infection (possibly due to both Alex Rios and Kelvin Herrera being from the tropics where the virus spreads poorly).

Chickenpox, once a horrible rite of passage, has now been relegated to a rarity given the prowess the varicella vaccine. This vaccine that has nearly vanquished a disease that just over two decades ago infected 4 million, hospitalized over 10,000, and killed 150 Americans yearly. Now those numbers are 95% lower. Additionally because the same virus that causes chickenpox can years later reactivate and cause shingles the benefit of the vaccine will be far reaching as shingles and its horrible after-effect of post-herpetic neuralgia require billions of dollars of medical treatment costs annually.

Chickenpox is a very contagious disease and for those susceptible because they are too young to be vaccinated, not vaccinated for medical reasons, or not vaccinated for deliberate non-medical reasons can, for certain individuals, be a serious disease. As such, I oppose chickenpox parties for obvious reasons though maybe those anti-vaccine parents who fondly recall their beloved experiences with chickenpox might try to book the Royals dugout to give their poor children that same experience.

Thank You Louis Pasteur

Yesterday was the 130th anniversary of Louis Pasteur's rabies vaccination of Joseph Meister--a day that everyone should recognize and celebrate. Though Jenner's smallpox was the first vaccine and Pasteur's called his rabies version "vaccine" to honor Jenner, Pasteur--in my view--is on the highest echelon of our race. 

Why I elevate Pasteur to that level has to do with the fact that not only did he discover the rabies vaccine but his contributions to the germ theory of disease (I'm not even counting  his contributions to stereochemistry) gave the entire field a green light to hypothesize, innovate, and advance. Such an achievement's ramifications are incalculable. 

To put it simply, I just would like to say thank you to Louis Pasteur for his recalcitrant, intransigent pursuit of the truth and that I am embarrassed that some members of our species have returned to the primitive status that humans have wallowed in for most of our history by shunning vaccination and pasteurization. 

The debt we owe Pasteur is not something repayable. 

Measles Still Has A License to Kill

The news of the 1st acute measles death in the US in over a decade is an event that should serve to remind those who doubt the ability of this virus, which kills 145,000 people per year, to inflict damage in the developed world. However, I doubt it because if people can blow off the 20% hospitalization rate that occurred during the Disneyland outbreak, one immunosuppressed person's death isn't enough to crack through layers of evasion.

I am interested to learn the details of this unfortunate case that resulted in a fatal measles pneumonia to see how the diagnosis was made, when it was made, and what confounding variables were present (I know no rash was present, something that occurs in the immunocompromised).

To date there have been 178 cases of measles reported this year, with nearly half of the 50 states being affected. The numbers are largely driven by the Disneyland outbreak that began last year.

Letting our guard down against this plague carries dire consequences.