Friday, April 12, 2013

A Pox on Health Reporting

Science and health reporting in the U.S. can be a bit of a mixed bag. Sometimes, reports on these topics are level-headed, presenting accurate information in the proper context. There is often a great deal of nuance involved. More often, though, news outlets do a less than optimal job. They oversimplify. They leave out important details. They get details wrong. They engage in inappropriate emotional appeals to spin the story, often to the detriment of truthful reporting.

You may have heard in the news, recently, of FrankieElizabeth Staiti, a 5-year-old New York kindergartener who has been barred from school because she has not received the varicella vaccine. The reason? Her pediatrician refuses to give the varicella vaccine to any child who has an infant sibling, believing that the varicella vaccine poses too great a risk, since it uses a live, weakened virus. FrankieElizabeth has a 14-week-old sister. Her mother, Elizabeth Wagner, applied for a medical exemption for her daughter, but it was rejected after the Department of Education reviewed it with her and FrankieElizabeth's pediatrician.

That is the basic story. But there are some problems with the way that a lot of outlets are reporting on this.

First up, it has been reported that Elizabeth has an autoimmune disorder, hypogammaglobulinemia. This autoimmune disorder has a number of different causes, but can be the result of inherited genetic mutations or congenital abnormalities. It makes the individual more susceptible to bacterial infections and, to a lesser degree, viral infections, because the body cannot produce sufficient antibodies to fight the infection. The disorder is rare, but those with a family history of hypogammaglobulinemia are at an increased risk of having the disease, as well.

While many of the news outlets are reporting, accurately, that Ms. Wagner has this disorder and that her infant daughter may have the disorder but that she cannot be tested for it until she is one year old, some articles, such as Lee Moran's article in the New York Daily News erroneously report that the infant does have an autoimmune disorder. This is lazy, shoddy journalism that only serves to distort the facts and sway public opinion against the Department of Education. But every story needs a villain, right? Who cares if truth is sacrificed in the pursuit of that goal?

Some reports are also engaging in scare-mongering hyperbole. Both the aforementioned NY Daily News article and WABC Eyewitness News say that if FrankieElizabeth gets the vaccine, she could "kill her baby sister". These words are chosen for their emotional impact, rather than journalistic necessity. Do these news sources give any basis for saying that? No. Do they make clear what, if any, risk there actually is for this? No.

The primary concerns appear to be that the varicella vaccine uses live, attenuated virus, meaning that there is a very small chance that FrankieElizabeth could shed the vaccine-strain virus for a period of time. It has been documented that viral shedding can occur for up to about a month after administration of the vaccine (though only 5 cases of vaccine-strain transmission have been documented out of over 55 million doses distributed). However, shedding does not mean that it will lead to infection in others. From what I could find, such infection can occur, but it appears to be very rare and of a much milder illness than wild type infection.

Which brings us to an important point. As Dr. Richard Besser states:
"You vaccinate the people around a baby because the baby doesn't have its own protection," he said, adding that the chicken pox vaccine uses a mild form of the virus to safely provoke a lasting immune response. "It would be much more dangerous for the older sibling to be unvaccinated and get real chicken pox."
That was one of the first things that occurred to me when I originally learned of this story. If the concern is that the infant is immunocompromised and, thus, at greater risk of complications from infection, then the risk of a wild type varicella infection is a much greater worry, as it will have a far greater virulence and chance of serious complications. The vaccine-strain virus is attenuated, meaning that it has been weakened so that it cannot replicate and cause a full-blown infection. Should shedding occur, the likelihood of it infecting close contacts is very low and, as I mentioned, even if it did manage to do so, it would result in far milder disease.

If the main worry is shedding of the vaccine-strain virus, the chances can be reduced by preventing contact between the two siblings for a period of time following immunization. This course of action allows the parent to have more control. Compare this to wild type infection. In children, often the first signs of chickenpox are the characteristic lesions on the skin. It can also be very difficult to determine exactly when an exposed child will first become contagious, since the virus can take anywhere from 10 to 21 days to incubate after infection. In this case of wild infection, it becomes even more important for the parent to isolate the children to prevent spread, and yet it is harder to know when to begin isolation. In essence, one is playing Russian Roulette against nature.

I don't blame Elizabeth Wagner, though, since it seems that she is just getting bad advice. As she has said regarding the option of pursuing a religious exemption:
"I did think about going that route, but I do believe in immunizations. It's not that I don't believe in them. But in this one case, it's a live virus and I'm not willing to take that chance with my newborn."
Under different circumstances and if she had received different advice, she may have otherwise quite willingly gotten the varicella vaccine for her 5-year-old daughter. There may still be a chance to show her that the benefits of vaccinating outweigh the risks, especially when one considers the risks of wild type infection.

But it appears she has received conflicting advice that creates a flawed moral dilemma: take an action and risk a very, very minute chance that her newborn will get sick vs. take no action and risk a greater chance of more serious illness for her infant. It is not an easy choice when you add emotions to the mix. In these sorts of scenarios, it is far easier to see taking no action as more morally acceptable. If you don't do anything, and something happens, it's outside of your control. You're removed from it. On the other hand, if you take action and something happens, there is a greater sense of personal responsibility for the outcome, even though you are responsible for whichever choice you make, no matter the outcome. Objectively, the better course to take is to opt for the vaccine and take reasonable precautions, such as keeping the two siblings apart until the minute risk has passed.

Although usually mild, varicella can be quite serious. Last year, a 3-year-old Minnesota girl, who was immunocompromised due to her rheumatoid arthritis treatment, was hospitalized after acquiring chickenpox from her younger sister. Neither one had been immunized due to personal beliefs of the parents, nor did the girl received post-exposure prophylaxis. She spent eight days in the hospital and thankfully recovered. She was certainly luckier than a healthy, 15-year-old Ohio girl who contracted the disease in 2009. Unfortunately, the course of her disease was quite a bit more serious. After three days of rash and one day of shortness of breath, she presented to the hospital, where she was admitted with a diagnosis of septic shock. For the first six hours, she received noninvasive ventilator support, but her ability to breathe deteriorated to the point of requiring invasive mechanical respiratory support. She received acyclovir, an antiviral drug used to treat varicella and other viral infections. Because chickenpox makes one prone to secondary bacterial and fungal infections, she was also placed on broad-spectrum antibiotics and antifungals. Sadly, she died after 21 days in the hospital.

I'll give the last word to the CDC, whose recommendations include vaccination of household contacts of immunocompromised individuals:
Vaccination of household contacts of immunocompromised persons theoretically might pose a minimal risk for transmission of vaccine virus to immunocompromised persons, although in one study, no evidence of transmission of vaccine virus was demonstrated after vaccination of 37 healthy siblings of 30 children with malignancy (155). No cases have been documented of transmission of vaccine virus to immunocompromised persons in the postlicensure period in the United States, with >55 million doses of vaccine distributed. Other data indicate that disease caused by vaccine virus in immunocompromised persons is milder than wild-type disease and can be treated with acyclovir (148,159). The benefits of vaccinating susceptible household contacts of immunocompromised persons outweigh the extremely low potential risk for transmission of vaccine virus to immunocompromised contacts.

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