V-Ticket to Ride

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

I haven’t been to Disneyland since my senior year in high school, and I’ve actually never visited one of the Disney World resorts. Frankly, I never really cared for the noise, the crowds and the artificiality of the Disney parks. The fact that one of these amusement parks is now the center of an infectious disease outbreak makes my aversion even more intense.

Public health officials in California recently confirmed that an outbreak of measles in that state has been linked to the Disneyland theme park in Anaheim. Over 90 new cases of measles have been reported in California and seven neighboring states during the past two weeks, with over 50 of those cases originating in the Magic Kingdom. Most of those cases occurred among unvaccinated kids.

To put this outbreak into context, consider that in 2000 the US Centers for Disease Control and Prevention (CDC) declared that measles had been eliminated from the United States due to vaccination programs and a strong system for detecting, reporting and responding to outbreaks. Only 37 confirmed cases of measles were reported that year, all of which were imported from other countries.

What a difference 15 years can make. In 2014, the United States experienced a record number of measles cases. 644 cases of measles were reported to the CDC, more than the total number of cases in the previous four years combined. If this year’s Disney outbreak is any predicator, we are likely to surpass the 2014 record.

The disease itself is still largely imported from overseas, but it spreads like wildfire among unvaccinated Americans. This is because measles is one of the most infectious diseases known to man. On average, a person with measles spreads it to 18 other people. By contrast, a person with Ebola (the deadly disease that caused widespread panic last year) is only likely to transmit that virus to one or two others, and only in places that lack a robust public health system. An outbreak of Ebola in the US is highly unlikely, whereas measles outbreaks will probably become commonplace.

The anti-vaccination movement is solely to blame for the re-emergence of measles as a public health threat. The easiest way to prevent the spread of measles is vaccination. If 95% of the people in a community are vaccinated against measles, outbreaks cannot occur. Unfortunately, rates of vaccination have fallen to their lowest levels since the start of widespread measles immunization programs in 1963. For example, over 40% of kindergarteners in Orange County, home to Disneyland and epicenter of the current outbreak, are not vaccinated against measles.

Those opposed to vaccination, including such public health luminaries as disgraced British researcher Andrew Wakefield and former Playboy Playmate Jenny McCarthy, have successfully convinced a large swath of the American public that vaccines are dangerous. Despite scientific evidence to the contrary, claims have been made that vaccines cause autism, cancer, asthma, allergies, and a host of other acute and chronic ailments. These so-called “anti-vax” claims have been largely accepted by a gullible populace. According to a recent survey, barely 51 percent of Americans believe that vaccines are safe and effective. About the same number of people also believe in astrology, creationism and ghosts.

Since the Disneyland outbreak began, a number of prominent anti-vaxxers have also argued publicly (including on the CBS Evening News) that measles is not a disease to be feared. Nothing could be further from the truth. Measles is a dangerous and deadly illness. Before the first effective vaccine was developed, approximately 4 million Americans contracted measles each year. Of those, 3 in 10 developed complications like pneumonia. Nearly 50,000 people were hospitalized, 1,000 were permanently disabled due to measles encephalitis, and 500 died.

When confronted with the lack of compelling data to support their claims, anti-vaccination activists often fall back on the most American of arguments: individual freedom and personal liberty. Specifically, many anti-vaxxers believe that the government cannot tell them what they should or should not put into their (or their child’s) body. But this position has limits, particularly when individual actions jeopardize the lives of others.

That is exactly the case here. When someone refuses to vaccinate themself or their kids, they put others at risk, including children who are too young to be vaccinated or elderly whose resistance to measles and other preventable diseases has waned.

It’s time for clinicians, public officials, and politicians to take a stand on vaccination, and take a stand against the claim that personal liberty trumps public safety. Pediatricians and other physicians should refuse to accept new patients who chose not to immunize themselves or their children. School officials should no longer allow unvaccinated children to attend public schools, except in rare cases where vaccination is contraindicated medically. Finally, local, state and national politicians should no longer make it easy for parents to obtain philosophical or “personal belief” exemptions from vaccination requirements and other public health statutes.

If you don’t like vaccines and refuse to get immunized, that is your right. But you shouldn’t expect to line up for Space Mountain or the Pirates of the Caribbean with the rest of us.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on January 29, 2015, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Manufacturing a Vaccine Controversy

by Sean Philpott, Director of the Center for Bioethics and Clinical Leadership

Last week, I got into an argument with a friend of mine about the flu vaccine. He felt that the vaccine was unnecessary and unsafe. In fact, he claimed, every time he’d been vaccinated, he came down with the flu.

Of course, everything he said or claimed in our discussion about whether or not people should be vaccinated against the flu was wrong. But this highly educated man is convinced that vaccines pose a serious threat to the health and well being of most Americans.

He’s not alone. Recent surveys suggest that over 40% of Americans believe that vaccines are unsafe. I’m not just talking about the flu vaccine. People are increasingly skeptical about the value and safety of all vaccines, including those that prevent such dangerous diseases as measles, whooping cough and polio.

Rates of vaccination in this country have decreased steadily over the last decade, particularly in more affluent and progressive communities. As a result, we are beginning to see a resurgence of otherwise preventable infectious diseases. For example, the US is experiencing the worst whooping cough epidemic in over 70 years.

Caused by a bacterium known as Bordetella pertussis, this disease is highly contagious and extremely dangerous, particularly for children. Over half of infants who catch the disease will require hospitalization. Some of these children will die.

Prior to the development of an effective vaccine to prevent whooping cough, nearly a quarter of a million Americans died from this disease annually. By the mid-1970s, however, the disease was largely eliminated in the US. Only a thousand cases of whooping cough occurred in 1976. Compare this with 2012, when nearly 50,000 cases were reported. Outbreaks were particularly common in Washington and Wisconsin, states that have some of the lowest rates of childhood vaccination.

All of this — declining vaccination rates, increasing skepticism about vaccine safety and effectiveness, and otherwise preventable outbreaks of dangerous infectious diseases — is the result of a militant anti-vaccination movement lead by celebrity ‘experts’ like former Playboy Playmate Jenny McCarthy.

The anti-vaccination movement is based on faulty science and fabricated research. The oft-cited claim that vaccines cause autism, for example, comes from a single now-discredited study by the fraudulent Dr. Andrew Wakefield. Despite this, the anti-vaccinationists increasingly have the support of the mainstream media.

For instance, Ms. McCarthy is the new co-host of the popular TV show “The View,” giving her a national platform to espouse her anti-vaccination opinions. Worse yet, veteran newswoman Katie Couric recently ran a segment on her talk show that questioned the safety and effectiveness of Gardasil and Cervarix, two vaccines that prevent the spread the most common cervical-cancer causing strains of human papilloma virus (HPV). The alarmist promo for that show: “The HPV vaccine is considered a life-saving cancer preventer, but is it a potentially deadly dose for girls?”

Katie and her producers, it seems, were more than willing to pander to fear-mongering anti-vaccinationists in exchange for ratings. The show’s guests included several women who made wild and unsubstantiated claims about vaccine safety and post-vaccination side effects. Known anti-vaccinationist Dr. Diane Harper also appeared on the show, questioning Gardasil’s effectiveness. Only one guest, Dr. Mallika Marshall, represented the pro-vaccination side. She was given but a few moments on the air, not nearly enough time to challenge the claims of the other guests. It was not exactly a ‘fair and balanced’ news segment.

Ms. Couric has since apologized, admitting in a Huffington Post blog that “criticisms that the program was too anti-vaccine and anti-science [were] valid.” Unfortunately, the damage is done and Katie’s apology, while seemingly heartfelt, did little to correct the myths perpetuated by the anti-vaccinationists who appeared on the show.

But we have a bigger problem. By even airing segments such as this, the mainstream media is actively promoting the idea that vaccines are neither safe nor effective. They are manufacturing controversy and debate where none exists.

The vast majority of studies show that vaccines are extremely safe and protect against a variety of dangerous diseases like whooping cough, influenza and cervical cancer. There is no uncertainty about the value of vaccines, at least not within the scientific and medical community. The benefits of vaccination clearly outweigh the risks.

That’s the news story the networks should be promoting, rather than giving anti-vaccination alarmists the opportunity to continue their campaign of misinformation and misdirection.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on December 19, 2013. It is also available on the WAMC website. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Princeton Meningitis Vaccination: Experiment vs Public Health Emergency

by Robert Baker, Professor of Bioethics and Director Emeritus of the Center for Bioethics and Clinical Leadership

As this post is being written, Princeton University is plagued by an outbreak of type B bacterial meningitis, a disease that has a 10% mortality rate in a college-age population. The first and only vaccine against this form of meningitis, Bexsero®, was approved last year in the two jurisdictions where type B meningitis is most prevalent: Australia and the European Union. The US Food and Drug Administration (FDA), however, has not approved the vaccine for use in the US. Consequently, Princeton’s trustees are seeking emergency authorization from the US Centers for Disease Control and Prevention (CDC) to use the vaccine.

One of America’s best-known bioethicists, Arthur Caplan, has written two blog posts on the subject — here and here. He contends that since Bexsero, “has not been approved by the FDA or other federal advisory agency…[those vaccinated] should be treated more as research subjects than as patients.” Here, Caplan is referencing regulations enacted in the aftermath of a notorious incident: the thalidomide tragedy of 1960. Back then, a newly hired FDA bureaucrat, Francis Oldham Kelsey, refused to rubberstamp a pharmaceutical company’s application for the  morning sickness drug, even though the drug had been approved for use in over twenty countries. Intrepidly insisting on a comprehensive review, Kelsey uncovered data indicating that thalidomide was linked to severe birth defects. She single handedly squelched FDA approval, and is thus credited with preventing birth defects in thousands of American babies. (Next July she will celebrate her 100^th birthday.) After the thalidomide incident, Congress required that the FDA independently review drugs approved in other jurisdictions before permitting their sale in the US. Bexsero is currently under review by the FDA but has not yet been approved for use in the US, so the Princeton trustees are appealing for an exemption from this requirement.

The circumstances surrounding the thalidomide case differ from those surrounding the Bexsero exemption. Thalidomide alleviated the symptoms of morning sickness, a non-lethal and non-infectious condition (albeit one that can be quite debilitating for some women). Delaying FDA approval to gather additional information on thalidomide’s safety did minimal harm to most pregnant women and protected the health of their unborn babies. Delaying an emergency exemption for Bexsero, by contrast, would allow the spread of an infectious disease that threatens the lives and health of the Princeton community, even though the known data offers no reason to suspect that the vaccine poses a safety risk.

Mindful of these facts Caplan concludes that Bexsero® should be offered to the Princeton students who, on his analysis, should be treated as if they were volunteering to serve as subjects in a study of an experimental drug. As potential subjects the students would be cautioned about unknown side effects and encouraged to reflect on their right to refuse to participate. I think this is the wrong model. Princeton students are not volunteering for a scientific study. They are members of a community at risk for contracting a sometimes disabling and often-fatal infectious disease. Emergency vaccination should thus be presented to them as the recommended choice. Students should of course be informed of the vaccine’s probationary status and of their right to refuse it; however, they should also be notified that if they refuse, unless they are isolated they may place not only their own health at risk but also the health of others. The Princeton trustees framed the issue properly when they notified students that, if the CDC grants an exemption, they recommend “students…receive a vaccine that helps protect against meningococcal disease caused by serogroup B.”

[The contents of this blog entry are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]