Deadly Choices: How the Anti-Vaccine Movement Threatens Us All - Paul A. Offit (2010)

INTRODUCTION

All horror movies start the same way. Whether the scene is an abandoned cabin, a dark alley, or a peaceful cottage, one line of dialogue, quietly uttered five minutes before the carnage starts, is inevitable: “Did you hear something?”

Such is the case with certain infections in American children. On February 17, 2009, Robert Bazell, a science correspondent for NBC Nightly News, told the story of an unusual outbreak in Minnesota: a handful of children had contracted meningitis caused by the bacterium Haemophilus influenzae type b, or Hib. What made this outbreak so unusual was that it didn’t have to happen; a vaccine to prevent Hib had been around for twenty years. But most of the Minnesota children—including one who died from the disease—weren’t vaccinated. The problem wasn’t that their parents couldn’t afford vaccines, or that they didn’t have access to medical care, or that they didn’t know about the value of vaccines. The problem was that they were afraid: afraid that vaccines contained dangerous additives ; or that children received too many vaccines too soon; or that vaccines caused autism, diabetes, multiple sclerosis, attention deficit disorder, learning disabilities, and hyperactivity. And despite scientific studies that should have been reassuring, many parents weren’t reassured. When the outbreak was over, one mother reconsidered her decision: “The doctor looked at me and said, ‘Your son is going to die. He doesn’t have much time.’ Honestly, I never really understood how severe the risk [was] that we put our son at.”

The Minnesota outbreak wasn’t an isolated event. In 2008 and 2009, outbreaks of Hib meningitis occurred in Pennsylvania, New York, Oklahoma, and Maine, killing at least four more children; in each case, parents had made the choice not to vaccinate—a choice that proved fatal.

Most parents today have probably never heard of Hib. But older doctors certainly remember it; so do grandparents. Before the vaccine, Hib caused meningitis, bloodstream infections, and pneumonia in twenty thousand children every year, killing a thousand and leaving many with permanent brain damage. Today’s outbreaks are a fraction of what they were in the past. But, as more parents choose not to vaccinate, more outbreaks of preventable infections are popping up across the country. And more children are needlessly harmed. The phenomenon doesn’t seem to be going away. So the questions remain: Have we heard something? Are these outbreaks just a blip on the radar screen? Or do they represent a deeper, far more serious problem?

Hib isn’t the only concern. Whooping cough, measles, and mumps—diseases once easily controlled by vaccines—are also coming back.

Whooping cough (pertussis) is a devastating infection. Before a vaccine was first used in the United States in the 1940s, about three hundred thousand cases of whooping cough caused seven thousand deaths every year, almost all in young children. Now, because of the pertussis vaccine, fewer than thirty children die every year from the disease. But times are changing.

Vashon Island is a small commuter island in King County, Washington. About ten thousand people live there, mostly well educated and affluent. The island supports an elementary school, a middle school, and a high school. Although schools on Vashon Island look like schools in any other upscale community, one difference isn’t immediately obvious. About one in seven children on the island is unvaccinated; in the middle school, it’s one in four. The consequences of this choice first appeared in the early 1990s. In 1994, the children of Vashon Island suffered 48 cases of whooping cough; in 1995, the number increased to 263; by 1999, it was 458.

Although whooping cough often starts benignly, it’s not a benign disease. Children with whooping cough first suffer congestion, coughing, and runny noses. Then they get the symptom that gives the disease its name. The bacterium that causes whooping cough, Bordetella pertussis, triggers the accumulation of thick, sticky mucus in the windpipe. Children try to rid themselves of the mucus by coughing; but it’s so gummy and tenacious that it’s impossible to cough up. Panicking, a child coughs and coughs—as many as twenty times in a row—without breathing in. Because these coughing spells deprive children of oxygen, many cough until they’re literally blue in the face. The long-awaited breath, taken against a narrowed windpipe, creates an unmistakable high-pitched sound. Parents who hear the whoop of whooping cough never forget it.

Coughing isn’t the only problem. Some children with whooping cough suffer pneumonia when pertussis bacteria travel to their lungs, or seizures when their brains don’t get enough oxygen, or suffocation when mucus completely blocks their windpipes. Some cough so hard that they break ribs or so long that they become malnourished.

Although Vashon Island is an excellent example of what can happen when parents stop giving pertussis vaccine, it isn’t the only example. On May 10, 2008, an outbreak of whooping cough occurred at the East Bay Waldorf School in El Sobrante, California. The Waldorf School follows the teachings of Rudolf Steiner, author of Fundamentals of Anthroposophical Medicine. Steiner believes that vaccination “interferes with karmic development and the cycles of reincarnation.” As a result of this philosophy, at least sixteen students, mostly kindergarteners, suffered the disease; virtually all were unvaccinated. When health officials investigated the outbreak—and discovered just how many children were left vulnerable—they did something that rarely occurs in twenty-first-century America. They closed the school until the epidemic subsided.

Pertussis outbreaks haven’t been limited to Washington and California ; they’ve also occurred in Delaware, Illinois, Mississippi, Arizona, Oregon, and Vermont. The outbreak in Delaware in 2006 prompted the Centers for Disease Control and Prevention (CDC) to issue a simple, frightening statement in its publication Morbidity and Mortality Weekly Report: “This age distribution is similar to that observed in the pre-vaccine era.” One city, Ashland, Oregon, has an elementary school in which not a single child is vaccinated.

Measles is also coming back.

On May 4, 2005, a seventeen-year-old unvaccinated Indiana girl boarded a plane to Bucharest, Romania. Sent on a mission by her church, she visited an orphanage and a hospital. She didn’t know that Romania was in the midst of a measles epidemic. On May 14, on the plane back to Indiana, she developed fever, cough, runny nose, and pink eye. The next day, she went to a church picnic attended by five hundred people. Although she felt ill, she was excited to share her experiences with her friends and neighbors. Neither she nor anyone at the picnic knew she had measles. On May 16, a red, speckled rash appeared on most of her body.

On May 29, two weeks after the picnic, the Indiana State Health Department received a phone call from a doctor in Cincinnati who recently had admitted a severely dehydrated six-year-old boy to the hospital. His diagnosis: measles. The doctor called health officials to tell them where the boy had been two weeks earlier: a church picnic in Indiana. The subsequent investigation was a case study in just how contagious measles virus can be. Among the 500 people at the picnic, 35 had never received a measles vaccine—31 of them (89 percent) became infected. Of the remaining 465 people, only 3 (0.6 percent) were infected. The girl who had contracted measles in Romania—after spending only a few hours in a crowd of 500 people—had managed to infect almost every person susceptible to the disease.

The Indiana outbreak was a frightening reminder of our past. Before 1963, when a vaccine was first available, measles was a common cause of suffering and death. Although most parents know that measles virus causes a rash, few know that it can also travel to the lungs and cause pneumonia or to the brain and cause inflammation (a condition called encephalitis), often resulting in seizures and brain damage. Worst of all, measles virus causes a rare disease called SSPE (subacute sclerosing panencephalitis), whereby children become progressively less able to walk, talk, or stand. Invariably they develop seizures, lapse into a coma, and die; despite heroic supportive measures, no child has ever survived SSPE. Before the vaccine, measles infected as many as four million American children, causing a hundred thousand to be hospitalized and five hundred to die every year.

Following the measles outbreak in Indiana, health officials at the CDC did everything they could to warn parents about the seriousness of the disease. They issued media alerts, health advisories, talking points, and educational materials, all with the hope that the alarm sounded in Indiana would be heard. But their warnings were ignored.

On January 13, 2008, a seven-year-old unvaccinated boy flew back to his home in San Diego after a family vacation in Switzerland. Nine days later he developed cough and a runny nose. His parents, who thought he had only a cold, sent him to school. But his illness worsened. The next day, the mother brought the boy to the doctor’s office, where he sat in the waiting room with other children. The doctor, unsure of the diagnosis, sent the child to a testing laboratory at a local hospital. Later that day, the boy was taken to the hospital’s emergency room with a fever of 104 degrees and a worsening rash. Because none of the attending doctors had considered measles, isolation precautions were never used in the doctor’s office, the testing laboratory, or the hospital.

Between January 31 and February 19 of that year, other children started getting sick: the boy’s two siblings, several of his classmates, and three children who had been sitting in the doctor’s waiting room. Again, the measles virus showed its remarkable ability to find susceptible children. Every child infected by the boy was unvaccinated. Of the three children who caught measles in the doctor’s waiting room, all were too young to have been vaccinated; one was hospitalized with severe dehydration; another traveled by plane to Hawaii while contagious. The measles outbreak in California shouldn’t have been surprising. In 2008, the parents of ten thousand California kindergarteners chose not to vaccinate their children.

California wasn’t the only state to suffer a measles outbreak. Thirteen other states—Illinois, Washington, Arizona, Hawaii, Wisconsin, Michigan, Arkansas, Georgia, Louisiana, Missouri, New Mexico, Pennsylvania, and Virginia—as well as the District of Columbia succumbed. When it was over, 140 children, almost all of them unvaccinated, had been infected; 20 were hospitalized. It was the largest single measles outbreak in the United States in more than a decade.

The Indiana and nationwide outbreaks shared one important feature: in both cases, the first infection occurred outside the United States. This isn’t unusual. Every year about sixty people traveling from countries where immunization rates are lower, such as Switzerland, Austria, Ireland, Israel, the Netherlands, Japan, and the United Kingdom, enter the United States with measles. Indeed, all of these countries continue to suffer measles outbreaks. But the situation in 2008 was different; this time measles spread from one unvaccinated American child to another to another. The problem wasn’t that national immunization rates were low; they were actually quite high. The problem was that certain communities had so many unvaccinated children that infections could spread unchecked.

Perhaps most disturbing was an outbreak of mumps among Hasidic Jews in New York and New Jersey—an outbreak that showed just how much we depend on one another for protection.

In June 2009, an eleven-year-old boy traveled to England and caught the mumps. At the time, thousands of British children were infected with mumps, primarily because their parents were afraid that the measles-mumps-rubella (MMR) vaccine caused autism. On June 17, the boy flew back to New York, attended a summer camp for Hasidic Jews, and started a massive epidemic. By October, two hundred people had been infected; by November, five hundred; and by January 2010, fifteen hundred. When it was over, mumps was found to have caused pancreatitis, meningitis, deafness, facial paralysis, or inflammation of the ovaries in sixty-five people; nineteen were hospitalized.

The mumps outbreak in 2009 showed that even vaccinated people are at risk. In order to stop the spread of infections, a certain percentage of the population needs to be vaccinated, a phenomenon known as population or herd immunity. People who aren’t vaccinated or who can’t be vaccinated will be protected when surrounded by a highly vaccinated group, much like a moat safeguards a castle. The fraction of the population that needs to be vaccinated to provide herd immunity depends on the contagiousness of the infection. For highly contagious infections—such as measles or pertussis—the immunization rate needs to be about 95 percent. For somewhat less contagious infections—like mumps and rubella—herd immunity can be achieved with immunization rates around 85 percent. Although 70 percent of the Hasidic Jews in the mumps outbreak of 2009 were vaccinated, the proportion of those protected was actually lower. That’s because no vaccine is 100 percent effective. For mumps, about 88 percent are protected after two doses. Therefore, although 70 percent were immunized, only 62 percent were protected, well below the rate needed to stop the spread of mumps.

The epidemic among Hasidic Jews wasn’t an isolated event. Three years earlier, in 2006, mumps had swept across the Midwest, infecting more than sixty-five hundred people, mostly college students.

The mumps epidemics of 2006 and 2009 proved that even vaccinated people might not be protected if vaccination rates aren’t high enough.

Outbreaks started by travel outside the United States won’t be limited to measles and mumps.

In 2003, rumors circulated in Nigeria that polio vaccine caused AIDS and made young girls infertile. Vaccination programs came to a halt. By 2006, polio originating in Nigeria had spread to twenty previously polio-free countries in Africa and Asia—more than five thousand people were severely and permanently paralyzed. “Such large-scale polio outbreaks haven’t been seen in quite a long time,” said Tammam Aloudat, a senior health official at the International Red Cross. Walter Orenstein, deputy director for the Gates Foundations’ Global Health Program, saw a parallel with the U.S. measles outbreaks of 2008. “Polio is only a plane ride away from the United States,” said Orenstein. “If we let our guard down, if our immunization coverage drops, there is certainly the possibility of a polio outbreak.” Orenstein doesn’t think it will end with polio: “Diphtheria could also come back. Any of them can. Because aside from smallpox, every other one of these infections is either in the United States or close to our borders.”

In the early 1900s, children routinely suffered and died from diseases now easily prevented by vaccines. Americans could expect that every year diphtheria would kill twelve thousand people, mostly young children; rubella (German measles) would cause as many as twenty thousand babies to be born blind, deaf, or mentally disabled; polio would permanently paralyze fifteen thousand children and kill a thousand; and mumps would be a common cause of deafness. Because of vaccines, all these diseases have been completely or virtually eliminated. But now, because more and more parents are choosing not to vaccinate their children, some of these diseases are coming back.

How did we get here? How did we come to believe that vaccines, rather than saving our lives, are something to fear? The answer to that question is rooted in one of the most powerful citizen activist groups in American history; founded in 1982, it is a group that, despite recent epidemics and deaths, has continued to gain followers in both the United States and the world.