The Vaccine Injury Court

That law, the National Childhood Vaccine Injury Act of 1986, limited the legal liability of vaccinemakers and created the National Vaccine Injury Compensation Program (VICP) in the Department of Health and Human Services. The VICP is a no-fault route for people injured by vaccines to win damages from a government trust fund financed by an excise tax on vaccines. (Despite the law's title, adults, too, can win compensation for vaccine injuries.) 

Since its first case in 1988, the vaccine court has adjudicated more than 16,000 petitions and dismissed two-thirds of them. To the successful petitioners, and their lawyers, it has awarded about $3.6 billion. The system has attracted scores of attorneys, who are paid hourly legal fees of up to $430 regardless of whether a claim succeeds. The court's website lists 195 lawyers nationwide who are willing to take vaccine cases, although petitioners can hire others. Many are clearly in search of their piece of the $3.7 billion sitting in the trust fund today. A sampling of the bold proclamations on vaccine lawyers' websites include these: “WE HAVE RECOVERED MILLIONS FOR OUR CLIENTS”; “Pursue Compensation”; and “NO COST to you.”

(snip)

THE VACCINE COURT'S DATA show that bona fide vaccine injuries are rare. For every million vaccine doses eligible for compensation that were distributed in the decade beginning in 2006, the court compensated one injury victim. Depending on the gravity of the disease in question, receiving a vaccine is orders of magnitude less dangerous than staying unvaccinated. The tetanus vaccine that Durant received causes a life-threatening allergic reaction in at most 0.0006% of people who get the shot. The U.S. case fatality rate from tetanus, by contrast, is 13.2%. “One injury from vaccines is one too many, but it is also important to keep perspective,” says Sarah Atanasoff, a physician at the VICP in Rockville, Maryland. “The benefits of vaccination to the individual, the local community, and the nation as a whole far outweigh the risks.” Petitions filed with the court suggest that among those real risks, shoulder injuries have become by far the most common. 

Rarer injuries include Guillain-Barré syndrome (GBS), a neurological malady associated with some influenza vaccines; anaphylaxis, a life-threatening allergic reaction that almost any vaccine can cause and occurs 1.3 times per million vaccinations; intussusception, an intestinal blockage that occurs in between one and five of every 100,000 infants vaccinated against rotavirus; and brachial neuritis (also called Parsonage-Turner syndrome), a painful inflammation of the nerves supplying the hand and arm, which afflicts up to 10 of every million tetanus vaccinees. Vaccination also can provoke (as well as prevent) febrile seizures, which occur in up to 5% of toddlers who become feverish for any reason. Those seizures are most common after measles, mumps, and rubella (MMR) or the combined MMR and chickenpox vaccine, occurring in up to 300 of each million children vaccinated. Typically lasting 1 to 2 minutes, the seizures can be frightening to witness. But they are transient and almost always without lasting effects.

(snip)

In fact, needles can do precisely that kind of damage if a vaccine is improperly administered too high on the upper arm, and the needle pierces the deltoid muscle and continues into the shoulder joint. There, physical damage from the needle and, more important, an immune reaction to the injected vaccine can provoke an inflammation that damages tendons, ligaments, and the fluid-filled sacs called bursas that reduce friction in the joint. Late in 2010, scientists in the government's VICP published a description of such injuries and gave them a name: shoulder injury related to vaccine administration. The government physicians, led by Atanasoff, had identified 13 adults who between 2006 and 2010 petitioned the court for compensation for shoulder injuries and submitted voluminous medical records. None had previous shoulder problems, but each had developed sudden, acute pain and a limited range of motion in a shoulder after a vaccination. Four patients needed surgery, and half of those needed a second operation. Their MRI reports showed shoulder joints riddled with inflammation. Half reported that the vaccine had been given “too high” in the shoulder. Most had received the vaccine in question—flu or tetanus, and in one case human papillomavirus—in the past, suggesting that the body's immune system was already primed to attack, in an immune response that led to serious, prolonged inflammation in the joint.

"Leaky" Vaccines

Interesting:

When people talk about the impact of vaccines, they usually mean the millions of humans saved from disease and death. But Andrew Read, an evolutionary biologist at Pennsylvania State University, University Park, likes to think about what vaccination does to pathogens. 

In 2001, he published a theory in Nature suggesting that some vaccines may cause viruses and bacteria to become more deadly. Now, Read has some evidence to back that up—at least in animals. 

A paper published in PLOS Biology this week suggests that widespread vaccination against Marek's disease, a viral infection in chickens, explains why it has evolved to become more lethal the past few decades. Something similar might happen with certain human vaccines, Read cautions. 

But other researchers say the study has little relevance for public health. Read “should stop scaremongering,” says vaccine researcher Adrian Hill of the University of Oxford in the United Kingdom. He and others worry that the paper—and news stories like this one—will only play into the hands of the antivaccine movement. 

Read's ideas are built on the widely accepted idea that pathogens often evolve to become less lethal over time. After all, killing their host quickly reduces their chances of being passed on, whereas causing mild symptoms, or none at all, should aid their spread. So-called leaky or imperfect vaccines, which don't prevent infection but merely reduce symptoms, upend that notion, Read argues. They allow the spread of deadlier pathogens that would normally burn out quickly. Leaky vaccines are common for animal infections, including Marek's disease. 

Most human vaccines, on the other hand, actually prevent infection, but that may soon change. With diseases like malaria or HIV, for which protection is very hard to achieve, researchers may settle for vaccines that save lives by preventing severe disease, but not infection. In the study, Read and his co-workers, working at the Pirbright Institute in Compton, U.K., showed that unvaccinated birds infected with highly virulent strains of Marek's disease didn't shed much virus; they also died too fast to pass the disease on to healthy, unvaccinated birds. But just as Read predicted, the opposite occurred in vaccinated birds: They shed more virus when infected with a virulent strain, readily infecting and killing unvaccinated cagemates. To Read, the result suggests that vaccines can favor strains that would otherwise be too lethal to spread. 

It's a convincing study, says Michael Lässig, who studies influenza evolution at the University of Cologne in Germany, “But it's a very special set of circumstances … I would be careful about drawing general conclusions.” Hill also thinks that Marek's disease may be a special case; nothing suggests that human vaccines have ever made a disease more virulent, he says. What's more, natural immunity is “leaky,” too, Hill argues, allowing infected people to survive and transmit a disease that is deadly to others. “For malaria, whatever today's vaccine does is a drop in the ocean of all the immunity that is happening in Africa from all the infections,” he says. 

Read suspects the phenomenon is more widespread. Feline calicivirus, which causes a respiratory infection in cats, also appears to have increased in virulence as a result of vaccination, Read says, and he is worried about the same thing happening with avian influenza, which some countries keep at bay with poultry vaccines. “You could have the emergence of super-hot strains,” he says. 

As for human disease, the study offers no support whatsoever for those who oppose vaccination, Read stresses. And if leaky vaccines are proven safe and effective, they should be used, he adds, but perhaps with closer monitoring and additional measures to reduce transmission, such as bed nets for malaria. “We need to have a responsible discussion about this.”

Definitely worth a discussion! But definitely true that natural immunity is leaky and can cause a similar effect. Why it happens with these few animal diseases is an interesting question.

"How one unvaccinated child sparked Minnesota measles outbreak"

CBS News:

A measles outbreak in Minnesota offers a case study of how the disease is transmitted in the United States today: An unvaccinated person travels abroad, brings measles back and infects vulnerable people -- including children who are unprotected because their parents chose not to vaccinate them.

That's the conclusion of a report published online June 9 in Pediatrics that details the 2011 outbreak that sickened 19 children and two adults in the state.

It began when an unvaccinated 2-year-old was taken to Kenya, where he contracted the measles virus. After returning to the United States, the child developed a fever, cough and vomiting. However, before measles was diagnosed, he passed the virus on to three children in a drop-in child care center and another household member. Contacts then multiplied, with more than 3,000 people eventually exposed.

Nine of the children ultimately infected were old enough to have received the measles-mumps-rubella (MMR) vaccine but had not.

In most of those cases, the child's parents feared the MMR vaccine could cause autism, according to researchers at the Minnesota Department of Health.

That idea -- first raised in 1998, by a British doctor named Andrew Wakefield -- has been discredited, said Pam Gahr, an epidemiologist who led the new research.

"But I think that as long as autism remains unexplained, the idea [that the MMR is a cause] will persist," Gahr said.

In the Minnesota outbreak, the child infected in Kenya was of Somali descent, as were most of the children whose parents had declined the MMR vaccine because of safety fears.

And that's consistent, Gahr said, with a striking decline in MMR acceptance among Minnesota's relatively large Somali population. In 2004, the number of Somali children in the state who were on schedule with their MMR topped 90 percent.

"By 2010, that was down to just 54 percent," Gahr said.

From what the health department learned in parent interviews, the decline seemed to stem from misinformation about an MMR-autism link.

Despite the unique circumstances of the Minnesota outbreak, though, measles can happen anywhere people are unvaccinated, said Dr. Andrew Pavia, chief of pediatric infectious diseases at the University of Utah in Salt Lake City.

"These outbreaks occur in all types of settings," said Pavia, who was not involved in the current study.

U.S. measles cases are at a 20-year high this year, the U.S. Centers for Disease Control and Prevention reported last week. As of May 30, the agency had received reports of 334 measles cases in 18 states.

Nearly all of the outbreaks involved unvaccinated people who brought measles back after a trip overseas, the CDC said.

The hardest-hit state is Ohio, where people in several Amish communities were infected after unvaccinated missionaries traveled to the Philippines and carried the measles virus back.

Amish communities have historically had low vaccination rates. And a 2011 survey of Amish parents who refused to vaccinate found that nearly all cited safety fears.

According to Pavia, the safety concerns of parents in the Minnesota outbreak illustrate the "power of bad information."

The MMR-autism link proposed by Wakefield was later found to be based on fraudulent data, and many studies since have found no connection between the vaccine and autism.

"Wakefield has been thoroughly debunked," Pavia said.

Gahr noted that these days, most parents never had or even saw a case of the measles. So some might dismiss it as just another childhood infection, she said.

But measles can prove serious, or even deadly. About 30 percent of people with measles develop a complication such as ear infection, diarrhea or pneumonia, the CDC says. Among children, one in 1,000 suffers brain inflammation, and one or two out of every 1,000 die.

"Even if you don't develop complications," Pavia said, "the disease is miserable."

Measles typically begins with a fever, cough, runny nose and "pink eye." After several days, a rash emerges around the face and neck, then spreads to the rest of the body.

"The thing is, we have the power to prevent it," Pavia said.

In the case of the Minnesota outbreak, he added, "the first infection that spread in the community was misinformation. The second was measles.

About that incidence of vaccine rejection in Somali US-born children... curious that this article doesn't mention anything about this:

A very interesting article was published today by Elizabeth Gorman on MinnPost.com that should be researched further: It might shine new light on genetic, and possibly environmental factors in autism.

The article reports that an unusually large proportion of Somali-speaking children in Minnesota have autism, something that has also been noted in Sweden, where Somali immigrants call autism "the Swedish Disease," because they did not see it back in East Africa.

According to the report, almost 6 percent of the Minneapolis school district's total enrollment is made up of Somali-speaking students. But in the city's early childhood and kindergarten programs, "more than 12 percent of the students with autism reported speaking Somali at home," and over "17 percent of students in the district's early childhood special education autism program are Somali speaking," the article said.

Somali kids with autism seem to be doing worse, on average, than their school mates: "About a quarter of all autism children who attend autism classrooms for students functioning too low to be mainstreamed in regular schoolrooms are Somali."

The statewide autism rate in Minnesota is already quite high -- at 100 per 10,000 children, as compared to the national average estimate of 67 per 10,000. In the Somali immigrant community, however, it could be much higher than either of those figures.

Why would that be? There is almost certainly a strong genetic connection at play here, but there may be other factors as well, including a lack of vitamin D from sunlight, (see the Swedish study in article) or, yes, vaccinations.

I do not know if vaccines are playing a role at all here. In fact, this report says that the Somali children were all born and vaccinated in the United States (though it seems to me that some must have immigrated here).

The "American Disease" idea comes from Somali parents themselves, and from some of the experts who work with them.

Anne Harrington, an early childhood special education coordinator for the Minneapolis school district and a specialist on the topic, told Gorman that Somalis "Are given more [vaccines] than we get, and sometimes they're doubled up. Then their children are given immunizations. In Somalia, their generations have not received these immunizations, and then suddenly they're getting just a wallop of them in the moms and then in the babies. That's certainly a concern that's been expressed to me by the Somali population."

I have never heard that before, and there may be nothing to it. On the other hand, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends that refugee adults receive at least 10 vaccines -- including pregnant women. Some of them contain thimerosal.

In addition, any of these kids who are older than five -- meaning they were born in 2002 or earlier -- could have received thimerosal in their vaccines.

Whatever the reason for the apparent higher rates of autism (ie, genes, sunlight, vitamins, vaccines, all of the above, none of the above) it is an interesting phenomenon and, it seems to me, an intriguing avenue of research.

There are data out there to suggest that elevated autism rates may not be limited strictly to immigrants from Somalia:

# A study of pervasive developmental disorder (a form of ASD) prevalence in Montreal school districts in 2003-2004 showed that the average PDD rate in the city's five predominantly French-speaking school districts (ie, largely Canadian-born) was 42.3 per 10,000 students, but in the largely English-speaking school district, where many immigrant children live, the rate was 69.2 per 10,000.

# In the English-speaking district, although the overall PDD rate was 69.2 per 10,000, among foreign-born children it was 106.6 per 10,000, and among Canadian-born children it was 67.6 per 10,000 - or 58% higher in the foreign born population.

# In Sweden, researchers reported that the incidence of autism among Somali immigrant children is far higher than among children living in Somalia (though better medical care and diagnostics would play a role, I'd think). Swedish media report that Somalis living in Sweden have dubbed autism, "The Swedish disease," because it is so common among Somali immigrants.

# These data might support reports that autism rates are also higher in immigrant communities in North America. On June 6, 2007, the Canadian Broadcasting News reported that, "autism rates are higher in immigrant families." Health-care specialists in Montreal, it said, were, "trying to understand why such a high number of autistic children come from immigrant families, a phenomenon seen in major cities across North America."

# This information MIGHT also help explain why autism numbers in California (and Minnesota, for that matter), are still high. In California, between 2003 and 2007, the rate of autism among black and white children enrolled in the state's DDS program increased by 50%. But the rate among Asian children in the same period went up by 79%, and the rate among Hispanic kids increased by 84.2%. The growth rate was about 58% higher among Asian and Hispanic children than black and white children.

# One in four California residents are foreign born. The majority are from Mexico, Central America, China, Korea, the Philippines and other countries with high vaccination rates (Mexico's is about 92%) and that still use the full amount of thimerosal in shots. Many if not most of these children are routinely revaccinated upon entry into the United States.

It would be very interesting, I believe, to look at autism rates in high and low immigration states. Not to implicate vaccines, but to find out if children of immigrants are more at risk than our native born population -- and why.

And:

Autism might not be any more prevalent among Somali-heritage children in Minneapolis than it is among white children in the city, but the severity of the developmental disorder appears harsher in this minority group.
In a much-anticipated report released Monday, University of Minnesota researchers found statistically similar rates of autism symptoms among 7- to 9-year-olds in Minneapolis, regardless of whether they were Somali or white. But all of the Somali-heritage children with autism also had related intellectual disorders — defined as scoring 70 or less on IQ tests — compared with a third of autistic children in the study overall.
“Somali children are much more likely to also have an intellectual disability, which means their symptoms, their characteristics, the ways in which autism presents itself in these children are very different,” said Amy Hewitt, the lead author of the study and a senior research associate in the university’s Institute on Community Integration.

Concerns about the prevalence of autism among Somali children surfaced among parents in 2008, and were validated in 2009 when a report from the Minnesota Department of Health found that Somali preschoolers were two to seven times more likely to receive autism services from the Minneapolis public school system. 

Polio Vaccine Politics, Particularly in Pakistan

Interesting piece on Democracy Now!

The World Health Organization has designated the spread of polio in Asia, Africa and the Middle East a global public health emergency requiring a coordinated "international response." Three countries pose the greatest risk of further spreading the paralyzing virus: Pakistan, Cameroon and Syria. In an unusual step, the WHO recommended all residents of those countries, of all ages, to be vaccinated before traveling abroad. The organization also said another seven countries — Afghanistan, Equatorial Guinea, Ethiopia, Iraq, Israel, Nigeria and Somalia — should "encourage" all their would-be travelers to get vaccinated. Until recently, polio had been nearly eradicated thanks to a 25-year campaign that vaccinated billions of children. In Pakistan, the increase in polio is being linked to a secret CIA ploy used in the hunt for Osama bin Laden. With the help of a Pakistani doctor, the CIA set up a fake vaccination campaign in the city of Abbottabad in an effort to get DNA from the bin Laden family. The Taliban subsequently announced a ban on immunization efforts and launched a string of deadly attacks on medical workers. We are joined by two guests: Rafia Zakaria, a columnist for Dawn, Pakistan’s largest English newspaper, who has been covering the rise of polio in Pakistan since the bin Laden raid; and one of Pakistan’s leading polio experts, Dr. Zulfiqar Bhutta.

Although the piece is anchored around the idea that the CIA caused this by setting up a fake vaccine program to get bin Laden, the reality is more complicated. Dr. Bhutta makes the case that the bigger problem is the ongoing unrest in Pakistan, the civil war against Islamic militants in tribal regions, and the US drone war is exacerbating the situation. Also, Dr. Bhutta doesn't think the WHO plan to immunize everyone traveling in Pakistan is at all feasible.

"Measles Outbreak Traced to Fully Vaccinated Patient for First Time"

Get the measles vaccine, and you won’t get the measles—or give it to anyone else. Right? Well, not always. A person fully vaccinated against measles has contracted the disease and passed it on to others. The startling case study contradicts received wisdom about the vaccine and suggests that a recent swell of measles outbreaks in developed nations could mean more illnesses even among the vaccinated.

When it comes to the measles vaccine, two shots are better than one. Most people in the United States are initially vaccinated against the virus shortly after their first birthday and return for a booster shot as a toddler. Less than 1% of people who get both shots will contract the potentially lethal skin and respiratory infection. And even if a fully vaccinated person does become infected—a rare situation known as “vaccine failure”—they weren’t thought to be contagious.

That’s why a fully vaccinated 22-year-old theater employee in New York City who developed the measles in 2011 was released without hospitalization or quarantine. But like Typhoid Mary, this patient turned out to be unwittingly contagious. Ultimately, she transmitted the measles to four other people, according to a recent report in Clinical Infectious Diseases that tracked symptoms in the 88 people with whom “Measles Mary” interacted while she was sick. Surprisingly, two of the secondary patients had been fully vaccinated. And although the other two had no record of receiving the vaccine, they both showed signs of previous measles exposure that should have conferred immunity.

A closer look at the blood samples taken during her treatment revealed how the immune defenses of Measles Mary broke down. As a first line of defense against the measles and other microbes, humans rely on a natural buttress of IgM antibodies. Like a wooden shield, they offer some protection from microbial assaults but aren’t impenetrable. The vaccine (or a case of the measles) prompts the body to supplement this primary buffer with a stronger armor of IgG antibodies, some of which are able to neutralize the measles virus so it can’t invade cells or spread to other patients. This secondary immune response was presumed to last for decades.

By analyzing her blood, the researchers found that Measles Mary mounted an IgM defense, as if she had never been vaccinated. Her blood also contained a potent arsenal of IgG antibodies, but a closer look revealed that none of these IgG antibodies were actually capable of neutralizing the measles virus. It seemed that her vaccine-given immunity had waned.

"Nonmedical Vaccine Exemptions and Pertussis in California, 2010"

Jessica E. Atwell, Josh Van Otterloo, Jennifer Zipprich, Kathleen Winter, Kathleen Harriman, Daniel A. Salmon, Neal A. Halsey and Saad B. Omer Pediatrics; originally published online September 30, 2013;
DOI: 10.1542/peds.2013-0878 

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2013/09/24/peds.2013-0878 

WHAT’S KNOWN ON THIS SUBJECT: Previous studies have shown that nonmedical exemptions (NMEs) to immunization cluster geographically and contribute to outbreaks of vaccine- preventable diseases such as pertussis. The 2010 pertussis resurgence in California has been widely attributed to waning immunity from acellular pertussis vaccines.
WHAT THIS STUDY ADDS: This study provides evidence of spatial and temporal clustering of NMEs and clustering of pertussis cases and suggests that geographic areas with high NME rates were also associated with high rates of pertussis in California in 2010.
BACKGROUND: In 2010, 9120 cases of pertussis were reported in California, more than any year since 1947. Although this resurgence has been widely attributed to waning immunity of the acellular vac- cine, the role of vaccine refusal has not been explored in the pub- lished literature. Many factors likely contributed to the outbreak, including the cyclical nature of pertussis, improved diagnosis, and waning immunity; however, it is important to understand if clustering of unvaccinated individuals also played a role.
METHODS: We analyzed nonmedical exemptions (NMEs) for children entering kindergarten from 2005 through 2010 and pertussis cases with onset in 2010 in California to determine if NMEs increased in that period, if children obtaining NMEs clustered spatially, if pertussis cases clustered spatially and temporally, and if there was statistically signif- icant overlap between clusters of NMEs and cases.
RESULTS: Kulldorff’s scan statistics identified 39 statistically significant clusters of high NME rates and 2 statistically significant clusters of pertussis cases in this time period. Census tracts within an exemptions cluster were 2.5 times more likely to be in a pertussis cluster (odds ratio = 2.47, 95% confidence interval: 2.22–2.75). More cases occurred within as compared with outside exemptions clusters (incident rate ratios = 1.20, 95% confidence interval: 1.10–1.30). The association remained significant after adjustment for demographic factors. NMEs clustered spatially and were associated with clusters of pertussis cases.
CONCLUSIONS: Our data suggest clustering of NMEs may have been 1 of several factors in the 2010 California pertussis resurgence. Pediatrics 2013;132:624–630

Isn't the more important issue whether or not the NME children had higher rates of Pertussis? Where is that data? (Yes, I know about the concept of herd immunity)

But seems to me like a lot of work here is trying to show that NMEs caused the disease outbreak.

Look at this figure from the article:

What on earth does this show? Looks like no association or maybe a random association.

And overall, they found 41 clusters of NMEs, and then describe two 2 clusters that had higher than expected pertussis. Except these last two clusters weren't described in the NME clusters.

Then they write:

Census tracts within a NME cluster were more likely to be in a pertussis case cluster than census tracts outside of a NME cluster (OR = 2.47, 95% CI: 2.22– 2.75). The association between the overlap remained significant after adjustment for proportion of racial/ ethnic minorities, population density, average family size, proportion of the population with a college degree, metropolitan area designation, and median household income (OR = 1.73, 95% CI: 1.53–1.96). 

The incidence of pertussis was higher within NME clusters than outside of NME clusters (IRR = 1.20, 95% CI: 1.10–1.30). The association remained significant after adjustment for demographic factors (IRR = 1.12, 95% CI: 1.02–1.23).

But where is the actual data for this? Why don't they show these numbers instead of the weird, poorly described data tables and meaningless figure (above) they do show?

The California Pertussis Epidemic, 2010

Interesting--

OBJECTIVE:
In 2010, California experienced the highest number of pertussis cases in >60 years, with >9000 cases, 809 hospitalizations, and 10 deaths. This report provides a descriptive epidemiologic analysis of this epidemic and describes public health mitigation strategies that were used, including expanded pertussis vaccine recommendations.
STUDY DESIGN:
Clinical and demographic information were evaluated for all pertussis cases with onset from January 1, 2010, through December 31, 2010, and reported to the California Department of Public Health.
RESULTS:
Hispanic infants younger than 6 months had the highest disease rates; all deaths and most hospitalizations occurred in infants younger than 3 months. Most pediatric cases were vaccinated according to national recommendations, although 9% of those aged 6 months to 18 years were completely unvaccinated against pertussis. High disease rates also were observed in fully vaccinated preadolescents, especially 10-year-olds. Mitigation strategies included expanded tetanus, diphtheria, and acellular pertussis vaccine recommendations, public and provider education, distribution of free vaccine for postpartum women and contacts of infants, and clinical guidance on diagnosis and treatment of pertussis in young infants.
CONCLUSIONS:
Infants too young to be fully vaccinated against pertussis remain at highest risk of severe disease and death. Data are needed to evaluate strategies offering direct protection of this vulnerable population, such as immunization of pregnant women and of newborns. The high rate of disease among preadolescents suggests waning of immunity from the diphtheria, tetanus, and acellular pertussis series; additional studies are warranted to evaluate the efficacy and duration of protection of the diphtheria, tetanus, and acellular pertussis series and the tetanus, diphtheria, and acellular pertussis series.

Hmmm-- "Most pediatric cases were vaccinated according to national recommendations" & "Infants too young to be fully vaccinated against pertussis remain at highest risk of severe disease and death."

A comment on the article from Caroline Soyemi, RN, MSN:

Winter et al¹ describe the clinical and epidemiologic characteristics of the 2010 California pertussis epidemic. They illustrate high disease burden and mortality in Hispanic patients, especially among infants, despite comparable vaccination coverage. The authors speculate that the high burden of disease in Hispanic patients might be caused by having larger households and possibly more contacts. Because the inference of a causal relationship between household size and high pertussis burden among Hispanics was not supported by data in this study, it would be beneficial if the authors considered doing an ecologic analysis by geocoding cases to census tract, aggregating case count by census tract, then using the census tract economic and housing data to understand factors that could further explain the high burden of disease as demonstrated in a similar study in which the authors used county-wide coverage levels.²

Previous investigators have demonstrated that occupational exposures to pertussis occur frequently in pediatric health care settings³ and that vaccination of health care personnel (HCP) is cost effective.⁴ The authors did not discuss the role that HCP might have played in the epidemic because they usually are the first to come in contact with infants, and infected HCP may be a source of infection.

Previous authors have demonstrated the presence of other Bordetella species in outbreaks ⁵ and thatBordetella parapertussis infections may contribute to cases thought to be vaccine failures. ⁶ Of the confirmed cases in this outbreak, 82% were laboratory-confirmed by polymerase chain reaction testing. Because this was a large outbreak with several thousands of cases, epidemiologic and clinical distribution of cases by species type would add to the growing body of literature and help readers understand whether there are changes in the spectrum of diseases caused by other Bordetella species.

I wonder about the effect of poverty on Pertussis-susceptibility, given that Hispanics in California, tend to be lower-income.

Hmmm:

Pertussis is a disease of the wealthy, according to the data from the California Department of Public Health. Their latest report, with data on the whooping cough epidemic in California through Nov. 9, 2010, contains the case counts and case rates by county. When those data are combined with data from the Census Bureau on the Latino population of California counties and the Department of Agriculture on median county income, a picture begins to emerge about the real demographics of this illness outbreak.

Twenty California counties have reported 100 or more cases of pertussis in 2010. Those counties contain 85 percent of the state's population, and 88 percent of the state's Latino population. They have reported, in total, 5,900 cases of whooping cough out of the state total of 6,631 cases.

Latinos have been the subject of intense speculation because the California Department of Public Health is reporting that the epidemic appears to be affecting Hispanic infants more than other races. CDPH only has hospitalization information on 40 percent of the cases and draws their conclusions on the epidemic's effects from those limited data.

Internet comments have accused illegal immigrants of being the source of the epidemic. Even officials at the Centers for Disease Control have suggested that Hispanic families have unique living conditions that are contributing to the epidemic.

Of the 20 California counties reporting over 100 cases of pertussis, eight have a higher percentage of Latino residents than the state's rate of 32 percent. These counties have about 44 percent of the state's residents, and are 58 percent Latino. These counties have reported 2,686 cases, 41 percent of the state's total. The average median income for these counties, as of 2008, was 25 percent lower than the statewide median income.

The remaining 12 California counties have Latino populations lower than the state average. They hold 41 percent of the state's population but only have a 29 percent Latino population. They have reported 3,214 cases of whooping cough, 49 percent of the state's total. These same 12 counties have an average median income that is 14 percent higher than the state's.

The CDPH weekly report has been showing for several weeks that whites have the highest rate per 100,000 for whooping cough infection in all age groups over 6 months. Hispanics have the highest rate in infants.

Infants do not receive their first vaccination for pertussis until age 2 months. About 600 cases have been reported in infants too young to have been immunized. The second immunization at four months and the third at six months both demonstrate a drop in cases numbers after they have been received.

The California whooping cough epidemic seems to be heaviest in areas that have fewer Latinos than the statewide average, and that have a median income well above the statewide average. It appears that income and race do play a role in the California epidemic, with well-to-do white people being the center of the outbreak.

Some comments about the Pertussis vaccine from Meryl Nass, MD:

Whooping cough is endemic, but seems to be increasing; looking at the vaccine role

Pertussis (whooping cough) cases are occasionally vaccine-resistant.

Sometimes what looks like pertussis is a related disease, parapertussis, and the pertussis vaccine is useless at preventing this infection.  In fact, the vaccine may actually enhance nasal carriage with parapertussis strains.

Usually, vaccine-induced protection is weak and doesn't last long.

Clearly a new vaccine that is safe and much more effective is sorely needed, for both conditions perhaps, but certainly for Bordetella pertussis (the bacteria that cause whooping cough).  Instead we are likely to be told to keep getting more frequent doses of the clunker vaccine.