Monday, March 12, 2012

Follow the Bouncing Ball

Back in January, I wrote about an outbreak of chicken pox at a day care facility. The outbreak involved four children, three of whom were siblings. One of the siblings was too young to receive the varicella vaccine. The three other children were all old enough, but their parents had not had them immunized due to a general distrust of vaccines. The facility was unaware that the kids were unimmunized because of two things: a) the parents allegedly faked their children's immunization records and b) the facility reportedly did not do their due diligence to validate the records. To make things worse, two of the day care staff were pregnant, one of whom had an uncertain history of immunity (either by vaccine or infection) to varicella, and thus was at risk for contracting chicken pox and passing it on to her fetus. In addition to increased risks to the mother (PDF), there would also be a risk of congenital varicella syndrome for the unborn child. To top it all off, the state in which this outbreak occurred does not require reporting of chicken pox cases unless they are fatal, so the whole thing may have gone unnoticed by anyone involved with public health.

That last bit is not the case in Alaska, where chicken pox cases are required by regulation to be reported to the Alaska Section of Epidemiology (SOE). I bring this up because, in 2011, Alaska's Kenai Peninsula also saw an outbreak of chicken pox at a day care facility. And, like the outbreak mentioned above, it occurred late in the year and also involved kids whose parents had eschewed vaccination.

The Section of Epidemiology received a report on November 3, 2011, of a case of chicken pox in a 7-month-old infant at a day care facility. Too young to have received the varicella vaccine, it is understandable that this child would be vulnerable to infection. As investigators looked into the case, they discovered that the child had been exposed to chicken pox at home through an older sibling. Their parents had used a religious exemption to opt the sibling out of receiving the vaccine. Subsequently, three more cases were diagnosed in the first week of November: two cases in infants too young for the vaccine and the third in another child whose parents had used a religious exemption to opt out.

According to the SOE report, local public health nurses and staff at the day care facility worked together to exclude any children who were susceptible to infection until the outbreak was over (21 days - one incubation period - after the last case resolved). Two children had religious exemptions, and three were too young to be vaccinated, meaning that five kids were kept out of the facility for at least three weeks. The rest of the children were age-appropriately immunized against the disease, including two attendees who had been previously exempted out of vaccination for religious reasons.

That last bit of information was a bit surprising. It suggests that the parents of those two children may not have really understood the risks of not vaccinating against preventable diseases until the risk was imminent. To them, the risk was either sufficient to override whatever religious convictions they had, or, as I suspect is more likely the case, they had simply used the religious exemption as a means of avoiding vaccines out of fear or misunderstanding. The SOE report suggests that increased awareness about vaccine-preventable diseases may go a long way to encouraging people to have their children immunized when, due to misperceptions of the risks involved, they would otherwise opt out. They include several recommendations to prevent outbreaks like this from occurring in the future:
  1. Health care providers should routinely educate parents regarding the ongoing threat of vaccine-preventable diseases and the importance of vaccinating their children with all of the recommended childhood vaccines according to the recommended schedule.
  2. Health care providers should inform parents of vaccine-exempted children that their children might be excluded from child care and/or school for extended periods of time during vaccine-preventable disease outbreaks.
  3. Concerned parents should be encouraged to ask about vaccine exemption rates at child care facilities and schools in order to make an informed decision about which facility is best for their children to attend.
  4. School leadership and child care facility personnel should strictly adhere to vaccination laws and not allow children to attend class or child care unless they are compliant with immunization requirements.
  5. Health care providers and school and child care facility personnel should promptly report all suspected outbreaks of varicella or any other reportable condition to the Section of Epidemiology via fax at 907-561-4239 or telephone at 907-269-8000 or 800-478-1700.
These are certainly sound recommendations, and are ones that everyone, even vaccine critics, should support. After all, we constantly hear from anti-vaccine activists that they want informed decision making. What we seldom hear from them, though, is that such informed decision making should also include being informed about those who opt out of vaccination and that should an outbreak occur, their unimmunized children may be, rightfully, excluded from day care or school to both protect them and help limit the spread of disease.

Another issue that is raised by this outbreak is that it should illustrate disparities between those who are financially well-to-do and those who have more limited resources. In order to prevent the spread of a disease during an outbreak, it is important to keep anyone who is at increased risk of infection away from areas where they are more likely to be exposed, such as at schools or day care facilities. For older children who are able to care for themselves during the day, this may not be too great a burden, but when a child is younger (e.g., an infant or toddler), then they will need someone present to watch over them during the day. Those who are well-off financially may be able to afford taking time off of work or even hiring a nanny. But for people who do not have extra resources and who may be more limited in their ability to take time off from work, weeks or months of staying at home to care for their child may put an undue strain upon the family, perhaps even cutting into necessities like providing food.

Whether a child is at increased risk of infection due to legitimate medical reasons (e.g., too young, immunocompromised, allergies, etc.) or for religious or philosophical concerns, that burden is one that can largely be avoided. As immunization rates go up, the risk of an outbreak goes down, since there are fewer people who could contract and spread the disease. And this aspect of an outbreak and outbreak prevention is something that should be explained clearly to parents, so that they really understand not only the risks of the diseases themselves, but also the broader social and financial implications that their decision may have.

The recommendations made by the Alaska Section of Epidemiology are all good ones, especially in a state that has one of the highest rates of exemption in the country, with 5.5% of kindergarten-aged kids exempting out of immunizations. However, I think an argument could be made for an even stronger recommendation, both in Alaska and across the U.S.

Medical exemptions already require that parents see a physician regarding their child's immunizations. Any state that allows religious or philosophical exemptions should also require that, before the exemption is granted, parents discuss the facts surrounding vaccines and the diseases they prevent with their pediatrician (or similar health care professional) and provide documentation to this effect. As Seattle Mama Doc wrote last year, Washington state passed just such legislation.

Granted, there are some limitations to how effective such laws may be. There are physicians out there who, despite all evidence to the contrary, believe that these diseases are not all that dangerous and that vaccines are, at best, only slightly effective (e.g., Dr. Jay Gordon), and who would be likely to simply sign off on an exemption without discussing the reality of the diseases and vaccines with parents. Some parents may comply with the law, but just sit through the physician meeting without actually listening or learning anything, secure in their misguided belief that vaccines are bad. Schools and day care facilities would also need to give parents ample time to make appointments before registration starts. While this sort of legislation may not ensure that every single child who can be immunized will be, it holds potential to increase uptake rates among those parents who are either on the fence or who have just been complacent about immunizations (a particular problem in states allowing philosophical exemptions, such as Washington) and will go a long way toward ensuring that parents receive information based on reality and science, and that they actually put thought and consideration into their decisions.

I encourage my readers to get in touch with their state legislators to inquire about current vaccine requirement and exemptions laws and to advocate for similar legislation as that described above. We all have a role to play in preventing outbreaks of diseases. Doing what we can to increase vaccination rates in our states is just one step we can take to help ourselves and our communities.
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