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.

Stories About People Who Don't Want to Get Their Kids Vaccinated Are in the News

Anti-vaccine movement is giving diseases a 2nd life (USA Today)

CDC: Vaccine "philosophical differences" driving up U.S. measles rates (CBS News)

How Many People Aren’t Vaccinating Their Kids in Your State? (Mother Jones)

Your Baby Back Ribs Will No Longer Support Anti-Vaccine Conspiracy Theorists (Think Progress) 

This Baby Has Whooping Cough, And Her Mother Wants More People To Get Their Vaccines (Think Progress)

Study: You Can't Change an Anti-Vaxxer's Mind (Mother Jones)


Most of these articles have vociferous debates in the comments section, with the pro-vaxxers decrying those who are against vaccines as anti-scientific conspiracy theorists, while the anti-vaxxers say the pro-vaxxers are brainwashed sheep or government shills.

This comment in the last article at Mother Jones is brilliant and does point out an interesting, odd trend in these debates:

It's remarkable that a magazine which focuses on corporate pathology and regales us with stories every issue of corporate malfeasance and captive regulatory failure would run an insulting piece of garbage like this vaccine rant... 

The most remarkable thing about the vaccine issue is the number of liberal minded people who are ordinarily highly skeptical of the pharmaceutical industry and the FDA, and who believe that huge swaths of our institutions and politics are broken, corrupt and pathological, yet then they succumb with complete unthinking compliance to the out of control vaccine industry and its lies and greed. 

This is the exact same industry which is of course run by the very same pathological craven drug firms and captive feckless FDA that media like Mother Jones is usually exposing. These industry hacks and government bureaucrats are the same people who proclaim that fracking is safe, that GMO food safe, that pesticides are safe, that cigarettes are safe, and on and on. As a matter of fact, today's leader on this web site is a story about broken science and phony claims of safety of BPA. 

Can one of you outraged vaccine drones explain why the vaccine industry is immune from the corruption and madness that has infected EVERY OTHER ASPECT OF PUBLIC LIFE? How many of you eat organic, avoid GMOs, clean with vinegar mixes, and oppose fracking? Don't you know that you are ill-informed: science has told us you are wasting your time. The government has blessed all of this. You foolish Luddites opposing fracking just because some celebrity told you to do it. Science has spoken: there is not one case of fracking causing contamination. It is SAFE, thousands of feet underground forever. The fracking chemicals are simple ingredients found in many kitchen cabinets. 

By opposing fracking, you are making us less secure and killing jobs. By opposing GMOs, you are literally starving millions of small African children. You are all selfish misinformed liberal kooks, and you should be forced to have a gas well in your backyard and eat GMO corn every day before you endanger us all with your stubborn refusal to do what you are told by a government that knows best. 

The list of failed efforts to control fraud and prevent serial contamination crisis's by the FDA is legion. The legacy of flat-out sociopathic malfeasance by the drug industry is documented fact. These are the people who are killing us and the earth, yet they get a free pass on vaccines. Despite all of this, for some mysterious reason, the same people who have legitimate doubts about corporate claims and regulatory effectiveness (and who often opt out of the corporate system in as many ways as possible), will then line up and get their shots without question. Talk about the people in need of some forced reeducation. 

The government's very real history of crimes and madness in secret involuntary public medical experiments, in covering up toxic dangers, and enabling corporate poisoning of the population ought to be understood by Mother Jones. I cannot imagine why anyone with even a modest understanding of our broken government and its pathological track record would blindly entrust it (and its drug company partners) and inject their infant children with an ever-growing list of chemical compounds, in vain hopes of creating a risk free world, somehow magically without consequence. It's you fear-addled sheep who are endangering us all with your blind compliance, misplaced faith in drug companies/FDA, and calls for public shaming and forced mandatory vaccines for everyone like some Terry Gilliam totalitarian dystopia. It is you who are spreading the hysteria. Sheesh. For shame Mother Jones.

This pro-vaccine versus anti-vaccine debate fascinates me. There are so many issues at play here, philosophical, scientific, statistics, epidemiology, public health, ethical, debating skills, emotions, and importantly for me as a professional immunologist, the real story of the immunology behind vaccines.

To be clear, I believe vaccines work and can prevent disease. At the same time, vaccines can be extremely harmful to some people. Knowing how well vaccines work in the general population is actually quite complicated due to so many variables. Here, I am interested in understanding the science and the truth about vaccines, since most of us have been heavily vaccinated and the number of required vaccinations has been increasing over the years.