History of Vaccines
The first vaccine was aimed at Polio, a virus which can render children and young adults permanently crippled or wheelchair bound or even ventilator dependent. Our experience in America is rife with the images of iron lungs, and even growing up in a small town of 10,000 I knew of an adult who was wheelchair bound from it.
Today, there are only pictures of that terrible past for us. In other countries, such as India, the disease ravages on. Access to the vaccine is the obstacle.
Whooping cough, known to me as a Pediatrician as Pertussis, used to be a rampant childhood illness also. Few of today’s Pediatricians have ever confirmed a case they have treated. It is hard, because the best test still requires a thin metal swab be inserted into the nose all the way to the very back of the nasal cavity. Very carefully the swab is rotated to sweep off some of the cuboidal epithelial cells of the mucous membrane there. Mucous and blood will not do and may cause the test to be falsely negative. Picture trying to do this in a 4 month old baby.
Now the swab has to be carefully rolled on the surface of a fresh, clean glass slide, so that the epithelial cells become adherent to it. The number of cells you get onto the slide is critical to the diagnosis of Pertussis. The bacteria adheres to these cells and the more you get the better. You see the slide must then be air dried and packed in a special cardboard transport package and sent off for testing. At the lab, the slide is treated with a special fluorescent antibody stain which sticks to the bacteria on the epithelial cells. If there are not enough bacteria or the epithelial cells that were collected didn’t have the bacteria attached to them, then there is no fluorescence. Thus a negative fluorescent antibody test for Pertussis, could mean that the test was truly negative, or falsely negative. There are few other tests that offer better results even today.
Measles is a viral infection which produces a rash and high fever. The tell-tale signs of the Koplik spots in the inside of the cheeks is very short lived. In addition to this, there are relatively few cases in the US because the vaccine is so effective. Because there are so many other viruses that causes rashes, what medical professionals call exanthems, most physicians have never seen a true case. I haven’t seen a bonafide case in my thirty-three years of Pediatrics, and if I ever considered the diagnosis, the clinical impression must be confirmed with serologic testing.
In the discussions about population immunity, what is referred to as herd immunity, the theory is that at some point if you get enough individuals vaccinated that you can eliminate the existence and spread of the disease. Those individuals who aren’t immune to the disease are then so spread apart by the individuals who are that all become protected. In cases of the original oral Polio vaccine, when you immunized a child, they shed that attenuated virus in their stool, and as a result other chidren and individuals who because infected with it, also could develop immunity.
Not all individuals who are vaccinated become immune to the targeted infectious agent. Developing an immunologic response to an infection is critical here. Vaccines are rated by their effectiveness at producing an immunologic response. I like to see vaccine responder rates of 90% to 92%. Rates of 95% are excellent.
Threats To Effective Herd Immunity And Infection Barriers
I see three threats with varying levels of concern toward the protection of population from diseases for which we vaccinate. Understanding these is very important especially when everyone is throwing in their two cents on how to deal with serious threats of infectious spread at the population level.
If the number of vaccinated individuals in the population drops to some certain level, then you will have more and more non-vaccinated individuals contacting other non-vaccinated individuals. Non-vaccinated individuals would include both those who were too young to produce a reliably adequate immunologic response, such as with measles and children under a year of age, and those individuals who have compromised immune health issues that precludes their vaccination.
It also includes those individuals who could have have gotten an immune response, but didn’t get the vaccine. The recent focus on American citizens who refuse the vaccines for their children however, have overlooked the more significant threat, which is individuals coming to our country unvaccinated. They pose a much bigger threat because by virtue of being outside our society, we have no way to monitor or encourage vaccination, nor do we know that the vaccines they received are ones that are effective, since vaccine manufacturers in other countries are not held to the higher standard generally required here in the United States.
Additionally, there is this thought that once you are vaccinated, that you’re good to go. That is not true however, as anyone sustaining a pentrating wound with a rusty nail would understand after they got a tetanus booster. This is particularly true of Pertussis which I mentioned already.
Not many medical studies really impact what Pediatricians actually recommend in the exam room. About a half dozen years or so ago, however a study came out which really caused me to tack in how I dealt with coughs in children. It turns out that an adult who has a cough that lasts two to three weeks has a 21% chance of actually having Pertussis. This is the prime reason we have to still be so vigilant even with a vaccination effort that has been effective but unable to mostly eradicate this disease. The repository of the bacteria is in the adult population whose childhood immunity has waned. As adults they don’t get as sick as infants, and most actually don’t go to a physician and get treated with the proper antibiotic. The usual antibiotics are all but ineffective agains Pertussis.
This adult repository is the reason that I recommend all parents of newborns that I see to get a Tdap, which is a tetanus vaccine that includes the Pertussis. Many hospitals are now starting to give the vaccine as well to the parents of newborns before they go home. I laud this, but the one problem in ERs and urgent cares is that many of them still give the Td tetanus vaccine which does not contain the Pertussis vaccine component.
Where Pertussis, which is called the Hundred Days Cough for good reason, can easily hide in the adult population by simply being a prolonged cough, Measles symptoms are not so easily undetected. High fever, coryza, and rash usually prompt an exam. Serious sequelae of measles is relatively higher than Pertussis. In the dozen or so cases of whooping cough that I’ve diagnosed in all my years have all responded well and none died. Measles can debilitate and kill.
To bring this all then back to three threats to preventing the spread of these infectious diseases in our country we have to pay close attention. The largest threat to our unvaccinated population of citizens comes from non-citizens who visit here or come illegally. Large amusement parks like Disneyland will promote the mix of those foreign individuals with our population. Similarly large warehouse-sized retail outlets are highly likely to be points of transmission of infectious disease. Personally I caution parents with newborns that Walmart and other large high-traffic stores are possibly a risk. Though I am guessing, I would suspect that many of the retailers might see 10,000 up to mabye even 50,000 people a day vist them. Contagion doesn’t have to be personal contact. I consider all the surfaces in those stores to be infection risk myself.
Clearly the biggest threat is the way our population mixes in normal life now compared with thirty years ago when superstores and large amusement were an rarity.
The second largest threat is from the waning immunity of our population. We are not vigilant enough as individuals toward vaccination as a lifelong thing. We associate vaccination with children.
Now we come the third threat I see from those individuals who are not vaccinated. While our citizens must be vigilant about Pertussis, these individuals can be vectors for disease. Unvaccinated popultions can include citizens of our country who can’t, or choose not to, be vaccinated. Those ‘antivaccine’ individuals actually make up a very small part of this. The problem is the non-citizens who are not vaccinated who visit or come and stay here illegally. The number of these individuals is so very much greater than citizens who choose not to vaccinate, yet I see this mostly ignored in discussions about forcing all citizens in this country to be vaccinated.
When a non-citizen comes to this country they do not have to show immunity to these diseases. Yellow fever is perhaps the exception. If you as a citizen visit certain areas of the world, you will be required to show proof that have been vaccinated upon reentry. This yellow fever certificate is as valuable as your passport. We don’t do this for measles. We don’t do it for Pertussis.
While presently there is a raging anger at those citizens who choose not to vaccinate, there is nothing said about foreign visitors who come to this country, and the conversation is even shunned when we discussed illegal visitors because of the current political correctness that is choking society.
What Should Be Our Priorities
If we are to eliminate the threat of such serious diseases like measles, then we must stop unvaccinated individuals at the border. We already do this for Yellow Fever so this is not novel. We must start admitting that illegal immigration carries more than political and ecomonmic implications. The health implications are the ones that will bring home the serious illness to our children.
We must stop being angry at those citizens who choose not to vaccinate their children. As a Pediatrician I think they should vaccinate and that the vaccines are safe. As a free citizen, however, I cherish the freedom that our country was founded and built on. It is no different than free speech. It is not only the ones who lose their freedom to choose, that lose their freedom. We all lose.
Many years ago in the new wake of the popularity of breastfeeding, I heard of a clinic in the Tulsa area where I trained, that stopped taking new infants whose mothers didn’t breast feed. Is that nonsense any different that medical practices who refuse to take children who aren’t vaccinated?
The most important way to prevent contagion in a medical office is to use appointment scheduling and stay on target with the exam schedule during the day. This prevents the mix of patients in the waiting rooms. Walk-in clinics are notoriously effective at transmitting infectious agents from one patient to another. Urgent cares and ERs are often very crowded, yet we see an alarming percentage of children who get almost routine healthcare there instead of establishing a regular physician relationship to private practitioners.
We stopped using paper on our exam tables long ago. The typical practice is in most practices to simply pull a fresh piece of paper over the exam table rather than actually clean the surfaces with an appropriate disinfectant.
Our policy is that we will try to take care of things that don’t need to be seen without a visit to our office. This makes not only good economic sense for parents, but good contagion prevention for the children we see.
I strive to develop good relationships with all my parents, even those who don’t want to vaccinate. Trying to force them goes against my grain, and will not be effective anyway. Developing a strong physician bond and trust can give parents a reason to decide to vaccinate. It is not that I’m trying to accommodate their decision, but rather give them access to my knowledge so they won’t be led astray by Dr. Google and all his non-medical cohorts. In a nation used to its freedom, there is marked push back when one group focuses on another over traditionally free-choice areas in our lives as though they are the bad guys