Here & Now

Noon Wednesday: Is Wisconsin At Risk Of An Outbreak?

Andy Moore:

Good Noon Wednesday everyone! Or maybe I should say, good 25 after Noon Wednesday. I’m Andy Moore, filling in for Marisa Wojcik, who’s on assignment in the field this weekend. This week happens to be the start of the school year, and so today, we’re talking about a topic many parents are considering this time of year, immunizations and I’m going to be talking with Dr. James Conway, a pediatrician, who specializes in immunizations with UW School of Medicine and the Global Health Institute. Statewide immunization rates are down for children. We’re gonna be talking about how that has happened, and why, in just a minute, but I want to start out with the very most basics and that is what are the primary diseases that children are getting vaccines for?

James Conway:

Well, I mean, measles, mumps, rubella is obviously the big one, the MMR shot that’s in the news now, but we give vaccines now for diphtheria, tetanus, pertussis, chicken pox, polio, hepatitis B, pneumococcus and haemophilus, which cause meningitis and pneumonias and bacteremias, blood stream infections. The litany of vaccines that have been made available over the last 40 years, really have allowed us to direct attention towards countless diseases now.

Andy Moore:

You were telling me earlier that they’re over 20, easily over 20 that just fall into a primary list.

James Conway:

Yeah, since 1985 we basically doubled the number of diseases we’re able to vaccinate against. So science keeps marching on and we keep trying to do what we can to protect more children.

Andy Moore:

How does vaccine work in the body?

James Conway:

Basically the idea is that when your body has a disease that you acquire at some kind of infection, if you survive it, it eventually mounts some immune response to that so that you’re protected in future contact with that disease. And the idea with the vaccine is basically doing something to trick the immune system into thinking that its already had the disease before, so that when you’re confronted by the disease your immune system says, I can handle this, I’ve already dealt with this before.

Andy Moore:

What was the first disease where that was discovered?

James Conway:

The first vaccine was the smallpox vaccine and it was so interesting that they basically realized that milkmaids who would get cowpox on their hands when smallpox epidemics would come through communities, didn’t get it. So this guy, Edward Jenner, got a little kid, James Phipps, and decided to try and actually gave him an injection of cowpox and proved that he was protected against smallpox and from the late 1700’s we’ve continued to move forward. Rabies and cholera were actually some of the next ones, that Louis Pasteur developed. And then since the 20th century dawned, we’ve been able to protect against more and more diseases.

Andy Moore:

So that kid was like the hero of the future of immunizations?

James Conway:

Yeah, he certainly was the first of many. It was also I think good public health observation that people in the public health field realized, that whatever would happen, milkmaids that would sometimes get these cowpox never got smallpox when it would come through communities. So that’s the beauty of public health and disease surveillance and good science, people kind of putting two and two together and realizing there’s something there.

Andy Moore:

As I said, as we started immunization rates are kept. The state keeps track of statewide immunization rates. Those are down. Tell us what the rate is currently and how that compares to 10 years ago.

James Conway:

Yeah well, there’s different ways that you can look at these numbers. If we look at the overall rate of kids being completely up to date with all their vaccines statewide, unfortunately we’re only just above 80%. However if we take each individual vaccine, fortunately most of our vaccine rates are just over 90% and 90% is a very critical number, which we can talk about a little bit. When we look at the vaccines that are required for school entry, which isn’t all the vaccines, that are routinely recommended but is kind of the bare minimum that people think are needed for school, we’re hanging out just a little bit above 91%. And that’s down, we peaked a couple of years back around 93, 94% and it’s been gradually decreasing.

Andy Moore:

I want to ask you, why you think that is, but go ahead and fill in the blank there on what that 90% figure means.

James Conway:

Sure. So when we think about a disease being introduced into a community we think about sort of what the herd immunity is, how many people are protected and when you’re above 90% of the people have received a vaccine and are immune, basically that’s only less one in 10 people are susceptible. And so if you think about it if somebody with a disease walks into a room, the odds that they’re gonna come into contact with that one person, measurable but small. And the odds of that person comes into contact with another person of the one in 10 is also small and so it prevents big outbreaks from happening. But if you get down to 80%, suddenly that’s only one in five people are vulnerable. So walking into a room, you’re pretty likely to run into the one in five and they’re pretty likely to run into one of the other one in five. So the difference between 80% immunization coverage and 90% immunization coverage is enormous and so that’s really what, when we talk about vaccine initiatives, for most diseases we want to be over 90%. For some diseases that are highly contagious, I mean measles which is what everybody’s talking about lately, is one of the most contagious diseases on the planet and so for measles you really want more than 95%, even 97% of the population protected, because otherwise you’re very likely of cases get introduced that you will start into an outbreak situation.

Andy Moore:

Speaking of highly contagious and measles, I thought I read that someone who is unprotected, who comes into a room where someone who has measles, but who left the room hours before and has been gone physically from the room that that person is still at risk.

James Conway:

Correct. I mean measles is one of the few diseases that literally as people cough and sneeze, which is how most of these diseases are transmitted, can literally linger in the air. There’s a famous outbreak from recent times after the World Cup in Germany a traveler came back and used an ATM in Boston, one of those closed ATMs and people over the next 12 hours that used that ATM, some of them who were unprotected came down with measles subsequently. So it was one of the more really frightening diseases from a public health standpoint because it is just so contagious and so difficult to control. The other problem with measles just as an aside is that the incubation period is very long and so after you’re exposed, you may not even realize you’ve been exposed, you will likely not come down with symptoms for about 10 to 14 days. And the scariest part is you can be contagious with the disease before you have full disease for a few days beforehand. So you have this long incubation, you may not even know you’ve been exposed to somebody, you’re contagious for a few days before you’re actually sick and know you need to stay away from people. And so when we look at this current outbreak, this is one of the reasons it’s been so hard to control in Washington State, New York state, is because of that long incubation and the fact that people are contagious without a lot of symptoms.

Andy Moore:

Well even the know you’re sick part is misleading from what I’ve been able to gather, because it comes on oftentimes presents as a head cold.

James Conway:

Absolutely.

Andy Moore:

I mean, who’s gonna be worried about that?

James Conway:

Exactly, running nose and cough and only a few days later do you get the crazy rash and high fever and all the other symptoms.

Andy Moore:

So I’ve feel like we’ve kind of gone a circle around the reasons why the rates are down and it appears from my doing a little bit of research that this connected with parents or guardians asking for exemptions.

James Conway:

Well that’s part of it, but I think you even need to back up a step before that and start talking about why are parents concerned and choosing to take those exemptions. There’s a number of reasons and I think there’s two very significant ones. One is we have become a victim of our own success and so as we’ve done a good job in a public health forum of immunizing most people and obviously we have good quarantine and good surveillance and good hygiene and all these other things that have evolved. We’ve gotten rid of a lot of these diseases at least to the point where they’re not on the tip of the tongue and in the public’s eye all the time and you combine that then with the rise of the unregulated media I call it, social media, and the Internet as opposed to kind of the responsible broadcast journalism that many of us grew up with where there was really an attention to making sure that facts were facts. You get this rise of concerns about the safety of vaccines combined with a lack of fear of the diseases, because rarely do people see these things and that leaves then to an understandable justification in people’s minds that it’s now okay to skip some of these vaccines. Our parents would have been appalled knowing that many of them had friends and colleagues that had measles or that had polio. The idea that you had a vaccine that was available and would choose not to get it would never even occur to them and it’s still the situation in much of the areas of the world where I work, but we’ve been a victim of our own success. Combine that with this movement towards trying to encourage people to be more educated consumers, to be more educated about healthcare, and you get the perfect storm, because where do people go for most of their information? They go to doctor Google, they put some terms in, and they start reading what they see and the problem is that there’s no referee that says these sites are credible and these one’s aren’t.

Andy Moore:

I hadn’t even considered the part about the absence of fear, sort of a starting point. What are reasons, there are several officially, that a parent or guardian can use, supply, to ask for an exemption for their children to be vaccinated?

James Conway:

Sure, well I mean every state permits a medical exemption, so if there’s a medical contraindication, you’re allergic to a component of the vaccine, or you have an immune deficiency and can’t tolerate certain types of vaccines, or if you’re undergoing something that suppresses your immune system and the thought is that you won’t even respond properly and be protected. So if you’re on chemotherapy or have a rheumatologic disease and have something that’s suppressing your immune system, there’s a lot of vaccines that are perfectly safe to give, but you may not respond to them. So those are considered medical contraindications. Every state permits people in consultation with their medical provider to say this is not a vaccine that’s appropriate for that kid and so there’s always going to be that portion of the population. Second is religious exemptions. About 45 states permit religious exemptions–

Andy Moore:

Did Wisconsin?

James Conway:

Wisconsin does. And religious exemptions, there’s very few religions that really do oppose vaccines. These are more for people who have firmly held beliefs that they feel conflicts with their religion.

Andy Moore:

Like Christian Scientists?

James Conway:

Christian Scientists are one of the ones that is legitimate, there’s a lot of people in many of the Christian faith that think certain vaccines are contraindicated by their religious teachings. In fact, when we’ve talked to religious leaders in most of those religions they really don’t have any particular opposition, but there are some legitimate faiths that do feel that these are things they should avoid and so 45 states permit those types of exemptions. And then the ones that I think you’re getting towards, the ones that we’re most concerned about are what are considered the personal conviction waivers or the personal decision waivers, which is basically that I don’t want to get my kid vaccinated and I don’t really need to give you a reason nor have any particular sound ideas or discussion with a medical professional. I just declare that I don’t want to do it.

Andy Moore:

And the personal exemption is allowed in Wisconsin?

James Conway:

Allowed in Wisconsin, it’s allowed at varying degrees in 19 states.

Andy Moore:

This is a population that goes beyond suspicion and stands with a flag fairly planted as against the science of the vaccine.

James Conway:

Actually it’s more complicated, as everything is, then that. There are actually very few people that are purely black and white on this and absolutely refuse to completely vaccinate their children. And I think that’s, so you’ll hear people use the term anti-vaxers or anti-vaccine. In fact, there are very few people that are truly anti-vaccine. The majority of people that sign waivers actually sign waivers around just one or two vaccines–

Andy Moore:

I was going to ask you if parents can selectively vaccine–

James Conway:

Yeah, they can in Wisconsin and many of these other states you can selectively opt out of just certain vaccines. And so that’s why when you asked kind of what are the immunization coverage rates, that’s why it’s a little tricky because what really matters to us is each antigen, each type of vaccine, and which are the ones that people opt out of. Now the concern is that the most common one that people opt out of is the measles mumps rubella vaccine and hence why we’re having these kinds of conversations, but no there are very few people that are truly, completely opposed to vaccines. Most people are what we call vaccine hesitant. So they are potentially not as fearful of the diseases themselves, they have some questions about the safety of the vaccines, or the need for them in their particular kid, and often what they really need is some dedicated educational time and time face to face with a medical professional. Unfortunately with everybody’s time being as crunched as it is, many of them resort to looking on the Internet and looking at Google for their answers and there is just so much misinformation out there that unfortunately misleads them.

Andy Moore:

Perhaps it’s because on any discussion on any topic the most strongly held, this gets into the world beyond the mainstream press too and out there on the Internet that people with the loudest voice are getting a lot of attention.

James Conway:

Very true.

Andy Moore:

But there they are, WisContext, our partners in journalism here did very good reporting on immunization recently and on their Facebook response got quotes like: “Vaccines are killing children.”, “Vaccines are not preventing disease, “vaccines give you the disease “you’re supposed to be protected from.” What do you say to those concerns because I’m just scratching the surface on the attention that their legitimate reporting brought them.

James Conway:

Yeah, I mean there is more and more of these kinds of false claims and the biggest problem that people need to understand is the difference between association and causation. And so what tends to happen is that people conflate something that happened to my kid with the most recent proximal event that happened, which in childhood is often the kid got a vaccine. I mean kids used to get vaccines basically every two months through the first couple years of life and if you’re kid gets a vaccine and then a couple months or weeks later somebody says I think you’re kid has a developmental delay, unfortunately people conflate the two and say the most recent thing that I can remember happening of significance was getting a vaccine and so there’s a lot of things that get blamed on vaccines, because they’re associated without any causation. And the ability to refute these is actually quite simple on the surface of it because the safety of vaccines is absolutely tantamount to everything we do. Vaccines are held to a completely different standard from drugs. The FDA, because you’re giving healthy individuals something with the goal of keeping them healthy. If your lipids are high and I’m giving you a drug to treat your lipids and your lipids get better, I’m willing to tolerate a little bit of side effects to that, but vaccines are very different. I’m giving them to a healthy person to keep them healthy and so we don’t tolerate much in the way of side effects. So when people ask why are vaccines so expensive? It’s because drugs are tested in usually five or 10,000 people. Vaccines before they ever even come to the FDA for review are tested in hundreds of thousands of people to look for rare side effects and then on top of that there is very, very tight vigilance on post-license share marketing surveillance where every vaccine that’s used is constantly under surveillance looking for rare side effects and so we have this enormous database of safety to be able to respond to people are concerned about the safety or the incident that they are concerned about for something that happened to an individual kid.

Andy Moore:

Does hammering away on the questions on safety, does it create a legitimacy even just because it’s so often discussed and is that a concern?

James Conway:

Yeah, I mean it’s like people say, there’s no such thing as bad publicity. I mean anything that continues to put things into the face of the public raises the legitimacy as a topic. So one of the things that’s concerning sometimes with the media, with all due respect in both the regulated and unregulated media, is this idea of providing fair balance. If there’s 98% of scientists that say that climate change is real, many of the media outlets still feel obliged to give the one or 2% an equal voice and so in the public’s eye those things become equivalent. We see the same thing in the print media with vaccine things is that for every story that really tells the real story of how safe vaccines are, what an incredible benefit they’ve been to societies, they’re still seems to be this compulsion to tell the other part of the story. Even if it’s one in five million people that complain that something may have occurred.

Andy Moore:

You got to bring it back to the media.

James Conway:

I apologize, I said with all due respect, so doesn’t that, that gives me carte blanche.

Andy Moore:

We’ll pull it to the curb with a practical question, especially for parents and families that are talking about this even as we do. If you had to recommend just one or two or just the small handful, we’d indicated there were 25 plus on the primary list of immunizations available, but if a parent comes to you and says, “Rank ’em, what are the ones that my kid needs?” What are you gonna say?

James Conway:

That’s tough, that’s like a Sophie’s choice in trying to choose over all the things that are of benefit. I mean I think we have to remember that vaccines are the most important public health measure we’ve ever achieved in society. When you add up all the lives saved from traffic safety and clean water and clean food and all these other things, in the United States and there’s clear data that vaccines have prevented more mortality and prevented more illness and what we call morbidity, then any other public health measure we’ve ever enacted. So then asking somebody to choose amongst those is somewhat challenging. I would say that of the things that we fear the most as far as how severe they are, measles, mumps, and rubella, especially given how severe and how transmissible they are, are clearly very important. Of diseases that are very frequent, the meningococcal vaccine and what’s called the Hib vaccine are also very important. Those are bacteria that many people become colonized with and are some of the more common causes of meningitis, pneumonia, ear infections, sinus infections, and things like that. But choosing just one would be extraordinarily difficult for somebody like me.

Andy Moore:

All right. Dr. James Conway is a pediatrician with UW School of Medicine, thanks very much for all your time today and we’re going to take some of this discussion to Health Services Secretary Andrea Palm. Secretary-designee Andrea Palm will be on our broadcast, our Here & Now broadcast Friday night at 7:30. So as always, the discussion continues, and we appreciate you sharing your noon hour with us. Marisa Wojcik will be back next week. I’m Andy Moore and we’ll see you Friday night on Here & Now.