Last month, my closest friend called repeatedly about her daughter (who I will call “Karen”) who is pregnant with her third child. This young mother-to-be developed a febrile illness, with a deep productive cough and myalgias, fatigue, headache, and chills, the classic presentation for seasonal flu. Ultimately, that was the diagnosis. Pregnant women are one of the identified high risk groups during an influenza outbreak.
According to the CDC:
“Flu is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from flu as well as hospitalizations and even death. Pregnant woman with flu also have a greater chance for serious problems for their unborn baby, including premature labor and delivery. Flu shots will protect pregnant women, their unborn babies and even protect the baby after birth.” (http://www.cdc.gov/flu/protect/vaccine/pregnant.htm)
Both Karen and her mom used to be my patients. My anxiety about her current illness was heightened when I learned that she did not receive a flu shot this year.
While vaccination does not completely eliminate the risk of flu related illness, strain-specific vaccines reduce the incidence of influenza by 75%, and also mitigate the severity of illness. The science of concocting flu vaccine each year involves the efforts of a vast army of life science experts.
According to the CDC:
“…130 national influenza centers in 101 countries conduct year-round surveillance for influenza and study influenza disease trends. These laboratories also send influenza viruses to the five World Health Organization (WHO) Collaborating Centers for Reference and Research on Influenza located in Atlanta, Georgia, USA (Centers for Disease Control and Prevention, CDC); London, United Kingdom (National Institute for Medical Research); Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory); Tokyo, Japan (National Institute for Infectious Diseases); and Beijing, China (National Institute for Viral Disease Control and Prevention) for additional analyses.”
This does not include all the efforts to monitor flu strains in wild birds and in chicken and pig farms around the planet.
According to an article by Fangjun Zhou, et al in the Archives of Pediatric and Adolescent Medicine (2005;159:1136-1144), routine childhood immunization for diphtheria, tetanus, pertussis, H influenzae type b, poliomyelitis, measles, mumps, rubella, congenital rubella syndrome, hepatitis B, and varicella saves us of $5.3 billion in medical costs and $16.5 billion in social cost, respectively vs the projected direct and social costs of suffering these diseases.
I can attest to the fact that Karen suffered mightily and incurred significant medical costs including two doctor visits and two emergency room visits, both 5 hour chaotic events even at the ER in a very upscale affluent hospital, and mucho medications. The social strains on her husband, children, and parents were not insignificant. She was acutely ill for almost two weeks and continues to be fatigued some four weeks later.
So, why didn’t she get vaccinated? For that matter, why doesn’t everyone get vaccinated? There are the simple reasons like no insurance, no money, no time, no regular doctor, etc. People lose track of time, having had a shot last year, but missing one this year. But more insidious are myths that are the ginned up to convince people they don’t need vaccines, and even more invidious are campaigns to convince people that vaccines are harmful.
People think vaccines are now superfluous. They think there is a drug that treats flu (anti virals help, but are not as effective as vaccination). They think that being sublimely middle class, exercising regularly, eating well and taking vitamins will keep your immune system so pumped that you do not need vaccination to stave off illness. And the most dangerous myth is that people do not die of diseases like flu anymore. SARS carried a mortality rate of 15% and H5N1 a rate of 50-60%, numbers that should disabused people of the fantasy that flu no longer kills.
Our collective memory is short. Most of us, even health care workers, have never seen someone die of influenza. Most Americans have never seen a child suffocate from diphtheria, once known as the “strangling angel of children.” Most don’t know that chicken pox in an adult carries a substantial risk of meningitis or encephalitis, coagulopathy and cerebellar ataxia. Few remember the terror parents felt each summer when polio outbreaks started. Travel to any poor area of the planet and the continuing scourge and anguish of childhood infectious disease is still apparent.
Fear is the next obstacle. Most everyone is now familiar with the notorious fraud perpetrated by Andrew Wakefield in a 1998 article in the Lancet implicating the mumps-measles-rubella vaccine (MMR) as a major risk factor in the development of autism. The Lancet and the co-authors have since retracted and renounced the claim, after it came to light that the data in the study were fabricated.
I have talked to a number of parents who want to rely on the action of others to protect their children. They fear that vaccines will harm their own offspring, and in a misapprehension about “herd immunity,” surmise if enough other kids are vaccinated, their own children escape the disease and risk of vaccination. These parents do not understand that if their own child gets sick, they put all children, even those who have been vaccinated at risk, though the risk is substantially lowered by vaccination.
The last major obstacle to vaccination is the obsession in the USA with individual responsibility and a lack of concern for our collective wellbeing, rooted in disregard for public health as a science. Mandatory vaccination is seen as an invasion of privacy, and intrusion into parental rights. Here in supposedly enlightened California, in 2010, 9,000 Californians were diagnosed with pertussis and ten infants died from the disease. In response, the California Department of Public Health, in partnership with local health departments and health care providers, developed a disease control strategy which included free vaccines at hospitals, especially for new parents to prevent transmission of the disease to newborns. Public service messages appeared on TV during “family” shows. Last fall, a new state law required students in 7th -12th grades to have a Tdap booster shot. The campaign has been supremely effective. In 2012, for the first time in 20 years, there were no whooping cough deaths in the state.
There is still work to do. Join us. Vaccine work is often seen as boring and mundane, not really interesting or innovative. But no public health intervention, except for plumbing, has been as effective in lowering mortality and extending life expectancy. We need better manufacturing techniques, more rapid vaccine production in response to new strain identification, and better supply chains. We need field epidemiologists. We need virologists. We need devoted clinicians. And we need to continue to share the benefits of vaccination with the entire world.
For a truly insightful look at this area, please read Vaccine: The Controversial Story of Medicine’s Greatest Lifesaver by Arthur Allen (WW Norton 2007)