Massive measles outbreak - thank you, Andrew Fucking Wakefield

The BBQ Pit
881

If you have a child with those sorts of conditions, there are all sorts of things you do differently. And, honestly, at least if there is a kid with measles in the waiting room at your doctors’, the doctor knows the measles were there and that you were there and how to contact you. Furthermore, the doctor knows to take precautions to sanitize any area the kid may have infected (I have no idea what the appropriate steps are there). A kid with measles passes through any number of other places and you never know.

Have any measles outbreaks been traced to a doctor’s waiting room?

882

No.

The measles outbreaks in recent years were tracked to importation from out of the country and in unimmunized people clustering together allowing it to spread (religious groups). They average about 60 cases in the country a year now. Last year was up including a cluster of 58 in New York alone.

Pertussis exposures have generally been in the schools or by family members. Vaccine refusniks are only part of that problem. The fact is that the current vaccine does not give as lasting of protection as the old whole cell one and not too many adults are getting an adult booster. They don’t so sick but thet pass it along to many as they cough for weeks.

The risk from exposure in a doctors office is near zero.

883

But certainly not zero. Remember the 2008 measles outbreak in San Diego? It started with a 7-year-old returning from Switzerland, who visited the offices of two physicians (one a pediatrician) ultimately leading to multiple cases and quarantines in the U.S.:

“Two generations of measles cases were identified. The first generation (eight cases) included the index patient’s two siblings, two playmates from his school, and the four children from the pediatrician’s office.”

The kicker is that “Patient Zero” (the source of the outbreak) was a patient of Dr. Bob Sears, a pediatrician who has popularized an “alternative vaccination schedule” which relies on delaying/spacing shots in an unscientific manner or avoiding them altogether. Dr. Bob now has that mess on his conscience (assuming he has one).

A hospital in Japan with unvaccinated pediatric inpatients also recently enabled a measles outbreak.

DSeid, I respect your wanting to ensure that children of ignorant/fearful parents get at least some worthwhile care, even when their unvaccinated status poses some risk to other children in your practice. I don’t see your it’s-only-a-tiny-risk position as a cop-out. But I certainly respect the position of other pediatricians who will not accept such patients in their practices; I don’t see them as guilty of a cop-out either.

884

The total infected in doctors’ offices then is the 4 from that incident and in an office that actually encourges refusnik behaviors. Of those 4, 3 were infants and the serious complication was a one 2 day stay in the hospital for dehydration. No second generation cases were traced to the office exposure. So one serious complication from measles traced to exposure in a doctor’s office. Yeah as close to zero as you can get without being zero. I think that you appreciate that as a matter of rational risk analysis this scarcely makes the case that there is anything other than infintessimal negligible risk incurred by seeing a pediatrician who does not refuse to case for the refusniks.

885

OK, I’ll bite…what causes autism? Please don’t kill me for straying from the topic:)

BTW, years ago, I read about a correlation between eating disorders and autism, specifically, autistic children’s mothers had had anorexia or bulimia before becoming pregnant.

886

…that we know about.

The point made in the linked article is that the infectious exposure apparently did not happen in Sears’ office, but did involve one of his patients. And if there’s a sizable cohort of patients whose parents insist on no or limited vaccination, it starts to become less important whether the pediatrician encourages them or not.

Yup, no biggie. :dubious:

What exactly do you tell parents who argue who see no need for vaccination, on the grounds that herd immunity due to a high rate of immunization of other kids means a “negligible” risk for their own offspring?

887

Why yes Jackmannii, when assessing risk we do not count the cases we have no reason to believe exist.

And yes, one child staying in the hospital 2 days out of all the kids seen in pediatricians offices, almost all of who do not refuse to care for vaccine refusers, over the past decade or two, is no biggie as a matter of risk. An extra few minutes of driving to a different office adds a bigger risk than that.

I tell them that they are wrong when they are and for the ones that they are not wrong that they are cheating in the social compact to take the benefit while others take to the small but non-zero risk. And that if enough people cheat like they do that herd immunity breaks down putting everyone at risk. That said that conversation is often the effective opening. Pneumococcus and Hib are still around enough that such passive herd protection to a small number of cheaters is not really operational. Pertussis is having somewhat regular flares. Rotavirus is still around a fair amount with the vaccine preventing severe disease that lands people in the hospital but not preventing all disease. I can concede that there is little risk to their child by their holding off on HepB and polio and later chickenpox but get them accepting that the risks of Pertussis, Hib, and Pneumococcal disease are still present and greater the younger you are … hence that getting those ones in matters most. And I keep the sales pitch up for MMR. By the time we get to a year there is a relationship established and getting them to comply with that too has a chance.

It is work and I wish I did not have to spend so much time doing it. And it is time completely wasted some fraction of the efforts; there are people who I never reach. I endure the frustration. My selfish best interest would be served by turning them away … we really are busy enough, thank you very much. But the ONLY reason to do that is my selfish interest. It is not serving the public health good or my other patients to refuse these kids care; it is harming those things.

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Athabasca, what we know for sure is what does not cause it: vaccines.

Not much else about autism is very well known, even if there really is an increase or just increased labelling, a widening of the diagnostic umbrella.

Clearly genes play the major role but they also are clearly not the only factor. One attractive hypothesis for a possible true increase is the assortive mating hypothesis: some certain load of certain sets of genes lead to some particular cognitive processing styles that have certain advantages in some vocations even if people with those genes tend to a bit less socially skilled. In past times those people were unlikely to mate together (sort of like herd immunity) but now they hook up on line due to common narrow interests or in the same professions. Maternal vitamin D levels, the rise of older parents, and changes in the microbiome have also been speculated as contributors. Certain infections increase risk as well. But mostly it is speculative.

889

Perhaps poor nutrition then?

890

DSeid, thanks for responding and for your contributing to this forum.

I wonder if as Guinastasia asks, poor nutrition can mean vitamin D deficiencies, as you mentioned. But the assortive mating hypothesis has me intrigued.

891

Vitamin D is generally more dependent on sun exposure than on nutrition.

I don’t know of the study that explicitly associates maternal eating disorders with autsm but there is an association of higher rates of a variety of psychiatric conditions within the families of those with autism, in particular OCD. Many kids with autistic spectrum disorders have disordered eating and some believe that a fair number of individuals with anorexia nervosa actually should be labelled as autistic spectrum. Assuming your recollection is correct (a reasonable assumption) then shared genetic predisposition seems most likely; anorexia nervosa being another related manifestation of the broad autistic phenotype that when self-assorted would increase the risk of full-blown autism.

892

In some parts of the world, though, nutrition is important for vitamin D. Not only the areas with little sunshine, but the areas where women are required to cover their entire bodies when outside the home.

I live in an area of London that has a large number of Muslim women who don’t always wear the veil (many do, but not all, and about 60% of the residents are Bangladeshi Muslims) but always cover the rest of their bodies. Vitamin D deficiency is so high that the local health authority will only pay for supplements in really extreme cases. This area does not have a corresponding increased rate of autism in young children.

No idea if this has anything to do with autism rates though. My daughter’s autistic and the most solid evidence I’ve read - no sources to link to - says it’s yet another of those conditions which has a genetic component which may be triggered by conditions at birth. Hence more identical twins with it, but not all.

My health during and before pregnancy couldn’t have been better, but the labour was very, uh, challenging, and my poor oxygen-deprived daughter was in the NICU for a week. I can’t help but wonder what child I would be parenting now had I asked for a different midwife.

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Those four cases (which I had to bring up to counter the “virtually zero risk” argument) only refer to documented cases of measles transmitted through a pediatrician’s office. There are many vaccine-preventable diseases that can show up in waiting rooms.

*"Lieber (a pediatrician who will not accept patients whose parents are outright vaccine refusers) says he enacted his policy about 11 years ago, “after an unvaccinated family walked into my waiting room with chicken pox.” Last week’s incident in which a woman with measels flew through Denver put more fuel on the fire for him…
“I feel like I have a bigger responsibility to all the other kids walking through my waiting room,” Lieber said. *

Dismissing the nearly one-quarter of pediatricians who in one survey would refuse non-vaccinated patiients as “selfish” may produce a nice warm sense of self-righteousness, but it doesn’t begin to address the issues involved.

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WhyNot, have you made a post describing your experience and how you came to change your mind? I’d be very interested in learning about it.

895

Thanks for the recommendation! I’m getting it for my 10yo who likes (and yes, I’m quoting her) “depressing books about epidemics.”

I think I might be able to offer insight. I go to a gynecologist who I think is well trained and smart, and who handles my lady problems very well. But, given a choice, I decided to reject her as an obstetrician for my two pregnancies. Granted, it’s not because I think there’s an active conspiracy to give pregnant women unnecessary interventions. But I can simultaneously believe that her education, peer reinforcement, and hospital procedures combine to create a risk of less than the best evidence-based care, and that on other topics her training and expertise are quite valuable.

I suspect anti-vax parents going to mainstream peds have a similar set of beliefs - the doctors just aren’t up on the latest research and believe the old tales they learned in medical school, so they don’t know enough about vaccine dangers to assess risk appropriately.

Naturally I think my layperson’s view of obstetrics is based on reasonable evidence, and I don’t think that about anti-vax parents. :smiley:

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You’re welcome.

897

Dseid, I have been having a rather crappy day, and for some reason this phraseology made me giggle almost hysterically. Thank you for that, and for being the voice of reason to your patients.

Even when pitted against some crackpot with bunny ears and big breasts.

Regards,
Shodan

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I hope you appreciate the respect I generally hold you in but in this case you, along with those docs (if sincerely concerned about patient safety), are demonstrating that physicians can be just as irrationally fearful and innumerate as any anti-vax nutter.

Really? Worried about the horror that there was an exposure to chicken pox? Oh come on. Get a grip.

I stand by the statement that there is virtually zero meaningful risk. One documented case of a child being hospitalized for two days over many many years … even if that was off by an order of magnitude or even by two orders of magnitude … would be, given the n involved, virtually zero risk. You have not countered the claim: you have supported it.

The consequences however of refusing to care for these children, to the children themselves and to the community as a whole (including the rest of my patients) is potentially much larger. The clear result would be the clustering of at-risk individuals, no chance at selling any refuser on compliance in any form*, with more spread of disease - not only to those unvaccinated but to those vaccinated as well. I think you appreciate that while the unvaccinated get disease at a greater rate the vaccinated still represent the lion’s share of those who get sick when an outbreak occurs. They are not catching it in the doctor’s office; they are catching it at school, church, the grocery store, the playgroup … Plus now these families are more likely to be an environment that not only validates and reinforces this particular bit of insanity but also a bunch of other woo.

To some degree this is analogous to why we kept using the oral polio vaccine (OPV) for 21 years after the last identified case of indigenous wild polio in the United States despite the fact that the (OPV) caused 8 to 10 cases of vaccine associated paralytic poliomyelitis (VAPP) cases every year. Yes, given the n, those 8 to 10 annual cases of VAPP were considered insignificant in comparison to the public health advantage that the OPV had over an IPV schedule even for years after there were no more wild polio cases to be found in the country. It was still 9 years after the last case anywhere in the Americas until OPV use was ceased.

Yeah my compatriots shirking their responsibility pisses me off and it is not just theoretical to me. It is not to enjoy the warm glow of self-rghiteousness either. (Although anything warm is appreciated this winter.) I don’t want to have to take care of any more than my fair share of the nutters and these docs are in effect dumping the nutters (and the merely misguided) to some degree into my patient pool. It is really not too dissimilar to taking care of Public Aid. No group in my area wants to take care of very many Public Aid patients. It pays less than our private payers and our specialists get paid even less than we do … getting them to accept the referrals for specialty care historically has only been possible by promises that a specialist who does not accept my Public Aid referrals will not get my private payer ones either. As a group we make a committment to do our fair share of providing care to this population, even a bit more than our fair share. But we should not have to do much more than our fair share because others can’t be arsed to do theirs.

*If I can make the sale a fair percent of the time, over time, then I am sure that many of my collegues can as well. I am not that special of a snowflake. It’s what we do: sell healthy behavior choices.

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Shodan, happy I could amuse!

900

I don’t think I have. Basically, I was taken in by the Andrew Fucking Wakefield “study,” and the research that those around me steered me to was full of information about how vaccine preventable illnesses just happened to be going into decline through the “natural lifecycle” of the pathogens and with the rise of sanitation. Vaccination was presented as a coincidence that was correlated, but not causing the decline of vaccine preventable illness. Throw in some poisoning of our precious bodily fluids, some “natural immunity is stronger and lifelong” and a healthy dollop of libertarianism (“how dare they tell me what I MUST put in my body?!”) and you have a recipe for pseudoscience and social pressure that was just strong enough to persuade me that mandatory vaccination was Teh Evil.

My son had already had all of his vaccines, so it wasn’t an issue for me personally at that time, but I did feel properly guilty and outraged that I’d been lied to and bullied by the Medical Establishment and allowed them to vaccinate him.

And, here’s the big secret - there’s a lot of anti-vaxxers who secretly vaccinate their own children. I know this because I was at the time working the front desk at an alternative medical clinic where many community members would have their children’s vaccination records faxed for school (this was before many people had fax machines at home or used online fax services.) They would go through torturous logical leaps to apologetically explain to me how their precious snowflakes had to be vaccinated, or had been vaccinated before they “knew better,” but really, honest to gosh they were against vaccines now.

My daughter was born about 6 months after I left that job and constant contact with that community. So that’s when it became a personal issue again. She was a micropreemie, and there’s no special vaccination schedule for preemies (or there wasn’t then). They wanted to give her her first vaccines in her first week of life, even though she wasn’t due to be *born *for another four months. That made me very uncomfortable, and to be honest, it still does. I cannot imagine that there have been safety and efficacy studies on a decent number of micropreemies, because there just aren’t that many people who have been born as early as she was and survived. And since she was in the NICU where we scrubbed our skin raw before visiting and stayed away when we were sick, not going to grocery stores and malls and buses to be exposed to much, I declined to vaccinate her at that point, saying I would discuss it with her pediatrician when we were closer to her due date. The nurse didn’t even press a little bit, rather she snatched the paper away with an air of relief and, “Okay, no problem!” and I was never asked again in the NICU. Later when I got to know her better, she privately admitted she shared my concerns and wouldn’t have vaccinated her own baby had she been in that situation.

Once WhyBaby was at her due date, I had a good long talk with her pediatrician, who, much like DSeid, helped to break down for me the “really important” vaccines and got me to agree to those, while delaying the HepB and Chicken Pox (and maybe a couple of others; I don’t recall.) She used the baby’s preemie status as leverage, explaining that she was at much greater risk of having severe respiratory issues and complications than a full term infant.

Then I decided to go to nursing school. In order to do that, I had to take Microbiology. There, we learned a bit about immunology and how vaccines work, and the more I learned, the more I realized that the fears of antivaxxers are just fundamentally based on complete lack of understanding about how vaccines work and how much the immune system can handle. The idea that a half dozen vaccines at once is somehow “too much” for a baby’s immune system is ridiculous when you realize that the baby is already fighting off literally thousands of pathogens every day. I learned that naturally acquired immunity is not always superior, and that in the case of things like chicken pox is actually a liability when shingles is taken into account. I learned that they weren’t trying to give my baby the HepB because they thought she would be a drug user or sexually active, but because it’s difficult to get parents to bring teenagers in to the doctor (and parents overestimate when their children become sexually/drug active), so if you vaccinate babies, you get more people protected.

So then we got her caught up on her vaccines, and that’s the end of that story. :slight_smile: