Let Me Out!

Earlier this month, commuters in the San Francisco area were warned that they may have been exposed to the highly contagious disease measles after a student at University of California, Berkeley attended class and rode the Bay Area Rapid Transit (BART) while contagious. The student, who was unvaccinated, likely contracted the disease while traveling abroad. Take a virus that can remain viable in the air of an enclosed space (like a classroom or subway car) or on surfaces for up to about two hours, a large student population of a university like UC Berkeley, and hundreds of thousands of commuters each day and you have a lot of people that were likely exposed to one of the most contagious viruses known to infect humans. Just look at BART alone, which sees roughly 390,000 riders each day. Of course, not all of those will ride in the same car as the student, but we can expect that at the very least, several hundred people would have been exposed to measles each time he rode. Cars hold about 60-70 people, the virus lingers for a couple hours, lots of people getting on and off during that period, it adds up. We could see additional cases popping up over the next week or two. And that's not the only case that California has seen. As of February 21, there have been 15 cases of measles, with the youngest being only 5 months old, according to a CDPH teleconference. Compare this to last year, when there were only 2 cases by the same date.

Those 15 cases make up the majority of the 24 cases seen nationwide to date, with other cases seen in Hawaii, Massachusetts, New York, Oregon, Pennsylvania, Texas, Washington and Wisconsin. The cases are in those who traveled to other countries where there are current measles outbreaks (e.g., the Philippines) or where measles is endemic (e.g., India) or among those who have had contact with someone bringing the virus back from another country. Since measles was eliminated from circulation in the U.S. in 2000, the outbreaks we have seen since then have been due to importation by unvaccinated individuals, some too young to be vaccinated, and others intentionally unvaccinated. Note that none of the outbreaks in recent years has been started by a fully immunized individual. With the risk posed by importation of the disease, I started to think about what role quarantine might play in mitigating potential harm to the public.

Forging Potential Harm

In the United States, every school maintains records on the immunization status of its students. Which students are fully vaccinated? Which have medical exemptions? Who get a religious or philosophical exemption for one or more vaccines? In the event of an outbreak of a vaccine preventable disease, these records can be used by the school to figure out which students are at risk and should be kept home until the outbreak is over. Public health officials also benefit from these records, as they can report vaccination rates across the state. This can show which communities may be vulnerable to a disease outbreak and narrow down where investigators need to look for potential index cases or contacts during an outbreak.

I've written before about an instance where parents forged their children's immunization records so they could get into day care. In that instance, the unimmunized children developed chicken pox, creating a small outbreak of the disease that put the other children, as well as two pregnant staff members, at risk of infection. This raised the question of the legal liability to the parents for their actions, handily addressed by The Skeptical Lawyer. No charges were filed in that case, and it's unlikely that any legal actions would have prevailed, according to the Skeptical Lawyer. A couple months after my original post, there was a chicken pox outbreak at a day care center in Alaska's Kenai Peninsula. Just like the earlier case, the parents refused vaccination for their children, ultimately resulting in a small outbreak.

The issues raised by those two events came together recently, again in Alaska's Kenai Peninsula. A nurse at a public school forged parent signatures on four immunization documents, noting in one instance vaccine refusal for religious reasons.

Weaving Ethical Dilemmas

Imagine, for a moment, that a device existed that could recreate just about any experience a person could have. Not like a television, video game or movie. Not even like a virtual reality simulator. Instead, it interfaces directly with the brain, stimulating specific regions to fire so that the user is, at least temporarily, completely convinced that they experienced whatever event was played. Every sight, sound, smell, taste and touch, even the very emotions evoked, all created by the device in the user's brain. Want to climb Mt. Everest from the comfort of your own home? Just run the right program and when it's done, you'll feel like you have. Want to sit on a tropical beach, lounging with a cool drink in your hand and just admire the majestic ocean, waves rolling in to murmur on the sandy shore? Run a different program, feeling completely relaxed when it's over.

That's the premise of a novella I just finished reading, called The Dream Weaver, by Aaron Simmons, who wrote the story as part of the annual National Novel Writing Month (aka NaNoWriMo). The central character is Eric Bram, a fellow who kicked off the technology and producer of some of the best "weaves" on the market. Bram, however, is wracked with guilt as he learns about the growing issue of addiction associated with the Dream Weaver device, wondering what role he may have played in the spread of the problem. Simmons weaves (excuse the pun) an intriguing tale that hints at far more considerations than could fit in the brief tale. So, I thought I'd explore some of the things that came to mind as I read it. Feel free to add your own thoughts in the comments. If you don't want the book spoiled, I suggest giving it a read before continuing on below.

Mississippi Parent Group Working to Make It Easier to Get Sick

In the United States, every state has some manner of requirements for immunizations before children are allowed to attend schools or day care. They vary from state to state, with some requiring almost all of the vaccinations on the recommended immunization schedule, while others only require a smaller subset. Each state decides which ones they will require, and which they simply recommend. As with any medical intervention, there may be medical reasons that a person should not receive a vaccine. Usually, this is something like an allergic reaction to a previous immunization or one of the ingredients or because at the time the shot would normally have been given, the patient had an illness which contraindicated the vaccine. In other instances, the child may have a chronic disease or disorder that prevents safe immunization. Because of this, every state allows for medical exemptions to school immunization requirements. Nearly all states allow for a religious exemption, with Mississippi and West Virginia being the odd ones out. A smaller proportion of states allow for a broader sort of exemption: the philosophical (or personal belief) exemption. Like the laws requiring immunization, these exemptions vary by state (a map of which states allow which type of exemptions can be found at the Institute for Vaccine Safety).

As I mentioned, Mississippi and West Virginia are unlike the rest of the country, in that they only allow for medical exemptions from school and day care immunization requirements. However, a recent report in the Clarion Ledger discusses the efforts of one organization to change the law in Mississippi, by trying to pass legislation that would establish a philosophical exemption in that state.

VacTruth Alleges Bullying in One-Sided Account of Nurse-Patient Encounter

Anti-vaccine activists have a love-hate relationship with medical providers, be they nurses, doctors, pharmacists, whatever. They love to hate any medical provider that dares to question their anti-vaccine beliefs. When they encounter someone who strongly urges them to get vaccinated or to vaccinate their children, the nurse or doctor is invariably described as a "bully", "ignorant", "ill-informed", "brain-washed", "pharma whores" and so on. They push "propaganda" are paid by "Big Pharma". Any interaction is viewed through this lens, that the parent is right and the medical professional is hopelessly benighted or even downright evil. If they happen to have a poor bedside manner, so much the worse, though given how some anti-vaccine activists respond to science-based feedback, I might be a bit short-tempered, too.

Over the weekend, an anti-vaccine blog called VacTruth.com (why must anti-vaccine groups always use such Orwellian names?) posted a story entitled "Bully Nurse Harasses Parents of Unvaccinated Baby at Michigan Hospital". According to the account, an unidentified couple brought their child to an urgent care center in Madison Heights, MI after talking on the phone with a nurse at their pediatrician's office. Their son, called "Oliver" in the article, had cold symptoms, a low fever and an "acne-like" rash on his face. Following the advice, they reportedly went to the Detroit Medical Center at Madison Heights, where the admitting nurse, if the account is to be believed, suspected the child had chicken pox and subsequently harassed, ridiculed and bullied the parents.

Autism Speaks Sounds the Fear

An unusually warm winter evening. Mid-January, no snow on the ground and the sky overcast, with the light nearly gone and nigh setting in. One the damp street, cars carried their owners homeward in a dense pack, heading down the hill toward the river. As I neared the plaza for the event (the screening of a new documentary), a small cluster of individuals with signs were gathering on the sidewalk at the entrance. Since I was running a bit late, I did not stop to talk, though I had wanted to. They were members of an advocacy organization there to protest the organization that made the film.

On Wednesday, January 15, Autism Speaks, in conjunction with Massachusetts General Hospital's Lurie Center for Autism, held a screening of their new documentary, Sounding the Alarm. The group out front were autism self-advocates who were protesting the film because they feel that Autism Speaks siphons off funds from local communities through fundraising, then gives very little back, as well as their use of negative imagery and words. According to the Facebook event page, the film is described as resorting "to rhetoric of fear, pity, tragedy, crisis, and burden to talk about autistic people".

At any rate, I made my way into the conference center where the screening was held, found a seat, and settled in to see just what all was in the film.

Two Recent Studies on Pertussis

Source: U.S. Centers for Disease Control and Prevention

Over the past couple of years, and especially this year, there has been an increasing number of news articles about pertussis outbreaks across the United States. In 1976, we had a low of only 1,010 reported cases. Cases reports gradually increased over the 1980s and 1990s, reaching nearly 10,000 by the early 2000s. Then in 2012, there were 48,277 reported cases. As of December 14, 2013, there have been 23,009 cases reported for the year. With the recent uptick in whooping cough across the country, the big question is, unsurprisingly, why? What's causing it? There have been a wide variety of potential explanations: reduced or waning efficacy of the vaccine, declines in vaccine uptake, and changes in the pertussis bacterium itself. Several studies published this year may shed a little light on the issue, especially in terms of vaccine efficacy.

The question of vaccine refusal and its link to outbreaks is not particularly surprising. Published in the journal Pediatrics in October, "Nonmedical vaccine exemptions and pertussis in California, 2010", by Atwell, et al., showed that non-medical exemptions were one of several factors contributing to the 2010 outbreak of whooping cough in California, which claimed the lives of 10 infants. This finding is in line with previous research on the impact of non-vaccination on the risk of outbreaks (see, e.g., here, here, here, and here). Lack of vaccination increases the risk of infection for both the individual and the surrounding members of their community.

Likewise, we know that the immunity from the pertussis vaccine wanes with time, just like the immunity from infection itself. That's nothing new. But two pieces of the puzzle that popped up in the scientific literature recently might explain why efficacy seems to be declining faster than previously thought.

Just Missing the Mark Again, Katie Couric Airs HPV Followup Segment

Back on December 4, award-winning journalist Katie Couric aired a mindnumbingly bad episode of her show Katie. Throwing her credibility and journalistic ethics to the wind, she made her show a platform for the anti-vaccine organization SaneVax, which promotes the erroneous belief that Gardasil, among others, is horribly dangerous and is killing our kids, going so far as to make available a guide on how to blame the vaccine if anything bad happens to your child at some point after they receive it. The episode featured two women, one (Emily Tarsell, National Vaccine Information Center's Director of Gardasil Network Development) who blamed Gardasil for the death of her daughter, and one (Rosemary Mathis, Founder and Director of SaneVax) who blamed a wide range of non-specific maladies that her daughter experienced. Both guests have a vested interest in scaring people away from the vaccine. In addition, one of the primary investigators of the Gardasil (Merck) and Cervarix (GlaxoSmithKline) clinical trials, Dr. Diane Harper, appeared on the show to downplay the effectiveness of the vaccines, stating they only lasted 5 years, while overselling pap smears in such a way that it made the vaccine seem pointless. For the science and reality side of the "conversation", Couric included Dr. Mallika Marshall. Dr. Marshall did her best to point out the facts of the vaccines, but when the entire show was framed to generate fear and mistrust of the vaccine, she had a very difficult time of it.

While others focused on the myriad flaws and errors in the episode, I focused on the ethics, though I did include links to a number of other articles lambasting the show. As a journalist, Couric had a number of responsibilities to her viewers to seek out the truth and report it. Unfortunately, she and her producers opted for ratings. The Friday after the episode aired, someone at the show put up a lukewarm justification for how they opted to do the show. It did not offer any apologies, nor did it correct any of the misinformation from the episode. More criticism popped up, and Couric herself penned a "mea culpa" of sorts on the Huffington Post. It was a step in the right direction, but Couric still didn't go far enough to correct the errors and damage done by her December 4 show. She addressed some, but not all, of the problems the others pointed out, but she skipped over some very important points. To make matters worse, she did it in the wrong venue. Rather than devoting time on her show to the corrections, which would have been seen by the same audience as her original episode, she opted to address a completely different audience: the ones who were criticizing her and already knew what the problems were.

Well, it seems that the well-earned criticism has finally filtered through...kind of. This past Friday, December 13, Couric devoted her "Follow Up Friday" segment to HPV and the vaccines that prevent it.

Followup: Katie Couric Addresses the Criticism...Sort Of

Last week, Katie Couric, award wining reporter and host of her own talk show, Katie, threw journalistic ethics to the wind. She hosted a show on the HPV vaccines, engaging in false balance by propping up two anti-vaccine anecdotes as being not only valid, but equivalent to the scientific evidence supporting the safety and efficacy of the vaccine. The backlash from science bloggers, journalists and the public was fast and brutal, pointing out all the things Ms. Couric (and her producers) did wrong.

When lukewarm justification for the way the show was done appeared on the Katie web site, it was not an apology. It did not correct any of the errors of the show. In short, it failed the ethical obligation to "admit mistakes and correct them promptly". Today, Katie Couric posted an article on the Huffington Post titled Furthering the Conversation on the HPV Vaccine. While it goes part of the way toward correcting things, it isn't quite enough.

Katie Couric Chooses Ratings Over Ethics

The blogosphere, Twitter, even mainstream news outlets have been abuzz about a recent episode of Katie Couric's show Katie. The episode, which aired December 4, 2013, was on the HPV vaccine, a vaccine that prevents infection with a virus that causes cervical cancer, head and neck cancers, warts and so forth. To give you an idea of how Couric and her producers were going to frame the discussion, here's what the teaser said:

The HPV vaccine is considered a life-saving cancer preventer … but is it a potentially deadly dose for girls? Meet a mom who claims her daughter died after getting the HPV vaccine, and hear all sides of the HPV vaccine controversy.

This blurb could have been written by the National Vaccine Information Center. Just like NVIC's recent anti-flu vaccine ad and more generic anti-vaccine billboards, the topic is framed to emphasize fear and distrust of the vaccine. And after watching the show, I agree with the numerous critiques that have been levied at Couric and her producers. The flaws with the show have all been stated very capably, so I'm not going to bother repeating them. Nor will I go into detail about the human papillomavirus or the vaccines that prevent infection. If you are interested in learning any of that, take a look at the links down at the bottom of this post.

Instead, I want to talk about the effect that Couric's show may have, not to mention some of the ethical implications involved.