Patient Case Study: A Rare Neurological Disease Diagnostic Journey
(Opinion) David M. Higgins, Joshua T.B. Williams & Sean T. O'Leary: Measles Is Back — Coloradans Should Be Concerned
It was only a matter of time. As pediatricians, we are concerned by the first measles case in Colorado since 2019. We have anxiously watched for three years as measles vaccination rates have fallen in our state while cases have risen around the world.
Colorado was spared in 2019 during our nation's largest measles outbreak in 30 years. However, 1 in 8 Coloradan kindergarteners are not fully vaccinated against measles today, and our state is overdue for an outbreak.
Measles is extremely dangerous.
Prior to safe and effective vaccines, measles was responsible for an estimated 48,000 hospitalizations, 1,000 cases of encephalitis (swelling of the brain), and 500 deaths every year in the United States.
Measles is also highly infectious. After a contagious person leaves a room, the measles virus can float in the air and infect others for up to 2 hours.
According to reports, the teenager who contracted measles spent significant time at DIA during a busy holiday travel season and visited several counties before seeking medical care. What if those activities included grocery shopping, cheering at a Nuggets game, Holiday shopping at crammed outlet malls, or testing at school during finals week?
Time will tell if this case leads to a larger outbreak – the incubation period for measles is typically 8-12 days, and the rash often doesn't appear until several days into the illness course.
Why do we put our children and communities at risk when a safe and effective alternative is readily available?
Measles vaccines have been around for over 60 years and 97% of children who receive two vaccine doses are considered protected for life.
Children receive measles and other essential routine vaccines before starting kindergarten. In so doing, they not only protect themselves, but they also prevent the spread of disease to children too young to get measles vaccines (infants under age 1 year), people with cancer or weakened immune systems, and those joining our state from areas of the world with disrupted access to routine preventive healthcare.
Historically, most parents have fully vaccinated their kindergarteners in a timely fashion. However, recent vaccination trends in Colorado paint a concerning picture. Today, just four states have worse measles vaccine coverage rates for kindergarteners than Colorado, which sits at 87%. To prevent outbreaks of measles, over 95% of people in our communities need to have protection.
We must do better.
First, we must improve access to childhood vaccines. Many parents want their children vaccinated but face substantial barriers to vaccination. These barriers disproportionately fall on the most vulnerable in our state. Recent data from the CDC show severe disparities in vaccine access for children in marginalized racial and ethnic groups, families experiencing poverty, those without private health insurance, and children living in rural areas.
Next, policymakers and child vaccination advocates must continue their legislative efforts. We need to bolster resources, support for, and availability of the Vaccines For Children (VFC) program, which provides no-cost vaccines to children who might not otherwise be vaccinated because of inability to pay.
Accessibility of vaccination sites and provider visits must grow and be supported by adequate provider reimbursement. Established school vaccine requirements need to be tightened and enforced. Leaders in pediatric and public health need to partner with community leaders to build and maintain vaccine confidence and trust.
To parents and the public, we must do a better job communicating the benefits and value of vaccines. The evidence is clear: the benefits of vaccines greatly outweigh potential risks. Unfortunately, the proliferation of misinformation in recent years has left some parents wondering if vaccines are safe. It is okay to have questions; pediatricians welcome honest conversations with their patients and families. We want to help you make informed decisions for yourselves and your children.
The return of measles in our state should concern everyone. Now is the time to reaffirm our commitment to our fellow Coloradans and to raise our lagging vaccination rates.
— David M. Higgins, MD, MPH, MS, is a Colorado-raised general academic pediatrician and preventive medicine specialist who studies vaccine delivery and vaccine hesitancy. Joshua T.B. Williams, MD is a general academic pediatrician who studies vaccine safety, vaccine hesitancy, and vaccination equity. Sean T. O'Leary, MD, MPH, is a general academic pediatrician and pediatric infectious disease specialist who studies vaccine delivery and vaccine hesitancy.
Measles, Mumps: Experts Stress Vaccine Importance As State Investigates Wild Child Immunizations
The state is investigating whether Julie DeVuono, arriving at Suffolk County Court in April in connection to a fake COVID-19 vaccine card scam, falsified other immunization records. Credit: James Carbone
Until a measles vaccine became available in 1963, 400 to 500 people a year nationwide died of the disease and nearly 50,000 were hospitalized.
The danger of measles and other diseases for which childhood vaccinations are required is why questions raised about the accuracy of an Amityville pediatric practice's immunization records are so serious, experts said.
"If you have a school, or a classroom, where a lot of folks didn't vaccinate their kids, obviously it can spread from the unvaccinated kid to the other unvaccinated kids," said Arthur Caplan, a professor of bioethics at New York University and an expert on vaccine policy. "It's much more likely you're going to get an outbreak."
Amityville nurse practitioner Julie DeVuono, owner of Wild Child Pediatric Healthcare, pleaded guilty to two felonies in September in connection with falsely stating that she administered COVID-19 vaccinations, when she did not. Her attorney, Jason Russo, said she sold thousands of fake vaccination cards, and prosecutors alleged she made $1.5 million in profits, charging up to $350 per fake shot for adults, and up to $220 for children.
What to know
Waiting for proof of vaccination fraud or litigation could take years, said Arthur Caplan, professor of bioethics at New York University. Credit: NYU Langone Health
Health departments recommend additional proofThe Nassau and Suffolk health departments have expressed concern that, in addition to falsifying COVID-19 vaccine cards, Wild Child could have issued fake childhood immunization records for diseases including the measles, mumps and tetanus.
In October, they sent letters to all Long Island school districts recommending that they require parents of children with Wild Child records to provide proof of immunization.
It's unclear how many districts, if any, are following the advisories.
Russo said DeVuono did not issue fake records for state-mandated childhood vaccines, and she was not criminally charged with providing falsified non-COVID vaccines to children. But the state Department of Health said this month it is investigating whether DeVuono's fraud extended to those vaccines. It has not released evidence against DeVuono, citing the open investigation.
Police seized $900,000 in cash in connection with the Wild Child COVID-19 vaccination card scheme. Credit: SCDA
Some school districts initially followed health department recommendations to require that Wild Child patients obtain further proof of vaccination, from a blood test and, in the case of vaccines not easily detected through blood tests, from vaccination from a different provider.
Parents in some districts challenged those mandates, in some cases turning to attorneys who warned districts of legal action if they didn't back down. The Miller Place, Rocky Point and Smithtown school districts suspended their mandates pending findings from the state probe.
Caplan said the health departments were right to recommend blood tests and vaccinations now, rather than waiting for results of the state investigation.
"In an era where we've seen outbreaks [of diseases like the measles], you've got to be cautious," he said. "If you're going to wait for proof and litigate this in the courts, you could have a window of years" of potential outbreaks.
But attorney James Mermigis, who represents several parents who challenged district mandates, said forcing parents to prove their children are vaccinated, when there is not evidence Wild Child fabricated their kids' records, violates their civil rights.
Deadly viruses 'still around'Measles is so contagious that, pre-vaccine, almost every child in the country became infected with the virus by age 15, according to the American Public Health Association. Other diseases infected fewer children but killed a higher percentage, with diphtheria causing more than 15,000 deaths in 1921, before vaccinations against that illness became common, the Centers for Disease Control and Prevention says.
"Vaccines are considered one of the greatest accomplishments of public health in the 20th century, the 21st as well," said Richard Carpiano, a professor of public policy at the University of California, Riverside, and an expert on vaccine uptake. "There's often this argument in anti-vaccine circles that, 'We don't see these kinds of diseases anymore. Why do we have to vaccinate against them?' Well, we don't see them anymore because we're vaccinating against them."
Of the few U.S. Cases of diseases like the measles and hepatitis B, many originate abroad, in countries where vaccination is less common.
"These viruses are still around," said Dr. Leonard Krilov, an infectious disease specialist and chairman of pediatrics at NYU Langone Hospital-Long Island in Mineola. "So easing up on vaccines can allow a resurgence."
An unvaccinated child returning home from Israel in 2018 began an outbreak of 648 measles cases in Brooklyn, according to a 2020 study published in the New England Journal of Medicine. About 8% of those infected were hospitalized.
A vaccination rate of 92% to 95% typically prevents outbreaks, Krilov said.
Officially, between 97% and 98% of New York State kindergartners were immunized in the 2022-23 school year, depending on the vaccine, according to the CDC. Another 2.3% had provisional enrollment; 0.1% received a medical exemption.
Amount of vaccine record fraud unknownYet the real numbers could be different, Caplan said: "In private schools, compliance is sometimes run by people who don't support vaccination, and the enforcement is lax."
State health department spokeswoman Erin Clary said the department conducts random and targeted audits of schools' vaccine records each year.
Caplan said the extent of vaccine-record fraud is unknown.
Russo said Wild Child administered 500 to 1,000 vaccinations a year. The state health department declined to say whether it knows the number of children with Wild Child vaccination records, because, Clary said, the investigation is ongoing.
DeVuono has been a licensed nurse practitioner since 2002, state records show, although as part of a plea deal, she agreed to surrender her license. Kids-on-Call Pediatric Nurse Practitioner, P.C., the corporate parent of Wild Child, was formed in 2007, records show.
Mermigis said his clients' children received their childhood immunizations and shouldn't be required to get them again. Titer tests, which are blood tests that measure antibodies created by vaccines, are not always reliable, he said.
"You take five kids, they're all vaccinated, and three of them, the titers may show that they have no immunity, and two of them might draw titers," he said.
Mermigis added, "Say they're forced to get a vaccine over again. That could damage children to get these vaccines a second time."
Dr. Sharon Nachman, chief of pediatric infectious diseases at Stony Brook Medicine, said a repeat dose of a vaccine does not harm children. In a small percentage of cases, vaccines either don't create antibodies or not enough antibodies to be detected. For the measles vaccine, for example, about 15% to 20% of titer tests may be negative after the first dose, dropping to 5% after the second, she said.
Yet even if a child received a vaccine, if a test is negative, it's advisable to get another vaccination, in case the first one did not create antibodies, or not enough, she said.
"We don't take the chance and say, 'Oh, you're probably protected,' " she said. "We say, giving a second dose of a live vaccine is perfectly safe, because if you didn't make a [immune] response, you will, and if you made a response, all I'm doing is boosting it."
Rita Palma, of Blue Point, founded My Kids, My Choice, an advocacy group that instructs people on how to apply for vaccine religious exemptions, which were barred in 2019 for K-12 schoolchildren but are still available for postsecondary students. She said the government shouldn't interfere in parents' medical choices for their children.
"It should be solely the decision of the parent," Palma said.
But Donna Hallas, director of the pediatric nurse practitioner program at the NYU Rory Meyers College of Nursing, said parents can be influenced by anti-vaccine misinformation and don't have the medical knowledge to make a decision that could endanger other children or teachers. That includes people on chemotherapy who cannot get vaccinated, she said.
"It's about protecting the public, not just one person," she said.
Donna Hallas, clinical professor and director of the pediatric nurse practitioner program at the NYU Rory Meyers College of Nursing. Credit: NYU Rory Meyers College of Nursing
Vaccine support droppingThe politicization of the COVID-19 vaccine increased vaccine hesitancy, although few people are truly anti-vaccine, Carpiano said.
"Anything public health got bundled up with the idea of big government impinging on personal freedoms," he said.
The percentage of adults who say healthy children should be required to obtain the vaccine against measles, mumps and rubella to attend school fell from 82% in October 2019 to 71% in December 2022, with 28% stating that parents should be able to decide, even if it creates health risks for others, according to polls from the San Francisco-based health policy nonprofit KFF.
Vaccines are safe, with serious side effects like severe allergic reactions rare, the CDC says. "The disease-prevention benefits of getting vaccines are much greater than the possible side effects for almost all children," the agency states.
David Olson covers health care. He has worked at Newsday since 2015 and previously covered immigration, multicultural issues and religion at The Press-Enterprise in Southern California.
Comments
Post a Comment