Posted tagged ‘measles’

What’s the best timing for my child’s measles vaccine doses? Should we give them early?

May 7, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

As the US endures its largest measles outbreak in 25 years – one that’s almost certainly going to get worse before it gets better – we’re getting a lot of calls and questions at my office. What’s measles, what’s the best way to prevent it, when should the vaccine be given to adults and children? I’m going to do a series of mini-posts, just focusing on one question at a time. We’ll see how this format works out – let me know if you like it!

The measles vaccine is given as “MMR”, which teaches the immune system to fight off measles, mumps, and rubella. It’s a very effective vaccine that confers lifelong immunity. A single dose is about 93% effective, and two doses get that up to 97%. There aren’t many other preventive interventions in medicine that are even close to that good.

The first dose should be given between 12 and 15 months of age, though at this point I’d say 12 months is better. Why wait until 12 months? Earlier than that, babies may still have enough antibodies from their mother to partially block the effectiveness of the vaccine.

But in some circumstances, you should get that first dose early, as early as six months. If there’s a high risk of exposure, an early dose (though imperfect) will give at least some protection. That dose should then be repeated at 12 months. Who’s at high risk of exposure? Anyone who’s living in a community with cases of measles – that includes, as I’m writing this, areas of New York, Michigan, and California. Plus the Philippines, Israel, and Ukraine. And, really, most of Europe. If you’re traveling with your baby under 12 months out of the US (or even within the US), you should look at the news and talk with your child’s doctor about getting an early dose of MMR.

The second dose of MMR is traditionally given at age 4-6 years, prior to school entry. But that timing was chosen for purely administrative reasons –kids almost always come in for a preschool physical, and they also need doses of polio and DTaP vaccines, which must be given after the fourth birthday. But that second dose of MMR can be given much earlier. It will be just as safe and effective if given any time 4 weeks or more after the first dose. So if the first dose is given right at 12 months, the second dose could be given at 13 months (or, more likely, at 15 months, since that’s when the next check-up age falls.)

Again, if you’re living in or traveling to an area experiencing a measles outbreak, you should get that second dose early. There is no downside. Honestly, there’s no reason why any of our young babies should wait until age 4 to get it – it’s just a bit of history and convenience that placed the second dose at age 4. If your children do get the second dose early, keep in mind that they do not ALSO need a dose at age 4 (though a third dose will not be harmful, it’s just not necessary.)

 

More info:

The nitty gritty details about the history of the MMR vaccine and its timing

Measles from the CDC

Vaccines: Children have rights, too

February 9, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Some people who argue against vaccinations claim that vaccine policies infringe on their “rights”—their rights, as parents, to make medical decisions for their children. It’s a scary, misleading, and chilling message. We need to be careful about where one person’s rights end and the next person’s rights begin. We need to remember that children (their children, and your children too) have rights of their own.

For example, Dr. Bob Sears says in all caps “FORCED VACCINATIONS FOR CALIFORNIANS ARE ON THEIR WAY.” No, Bob. California lawmakers have introduced a bill to eliminate “personal belief exemptions” for public school attendance. No one is going to force any vaccines on anyone, and there are no jackbooted thugs on the way. But if you want to send your child to public school, they’ve got to be vaccinated. There’s still a religious exemption (which is odd—no major religions are against vaccinating) and of course a medical exemption. But “personal belief exemptions” shouldn’t hold water, because personal beliefs don’t prevent disease. Vaccines do. You want your kids in public school, with my kids? Then my kids’ right to have a safe school overrides your rights to not vaccinate your child. Simple.

How far do rights go? Until they start to infringe on the rights of others.

Dr. Bob goes on to say that mandatory school vaccines violate “a parent’s right to make all health care decisions for their child.” He seems to agree with statements from a few politicians in the news lately. Rand Paul, an ophthalmologist and Kentucky Senator, says “The state doesn’t own your children. Parents own the children, and it’s an issue of freedom.”

No, Dr. Paul. Children are not things to be owned. They are not property. They are people, and they have rights too. Do what you want with your own children—anything short of abuse or egregious neglect, and the government won’t interfere. But as soon as your “rights” start to threaten the health of other children, and of our entire communities, that’s where your rights end. And the rights of the rest of us begin.

Immunity, breastfeeding, and the timing of measles vaccine

January 27, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Leave it to Disney to make a splash—any day now, we’ll hear that Anna and Elsa have caught the measles themselves (imagine a link to the sisters all covered with spots, looking miserable in the hospital, with a worried snowman and moose cowering in the background. “For the first time in forever… measles is back….”)

I’ve already covered the outbreak in detail. Briefly: over the December holiday someone at one of Disneyland’s theme parks in California brought in measles. At least 5 employees and probably about 40 park visitors caught it, almost all of whom were unvaccinated. Since then, despite a massive public health effort to identify and isolate potentially infectious contacts, the outbreak has spread to about 100 cases in 6 states. Again, and this can’t be repeated too much, almost all of the cases are occurring in people who have not been fully vaccinated, either because they’re babies who are too young, or for other reasons. It’s not yet clear exactly what that breakdown is. Some of the cases could have and should have been vaccinated; it’s likely that others had health issues that prevented timely vaccination. In any case, since measles is super-contagious, it will likely continue to spread, especially among communities with poor immunization coverage. Sadly, this has been an entirely predictable and avoidable outbreak.

A few comments and notes sent in—thanks especially Emily and Jennifer–have asked for more details about the MMR vaccine and how immunity affects how it works. I feel another Q&A coming on….

 

Aren’t newborns pretty well protected against measles, from mom’s antibodies?

The placenta sends lots of important things to baby—oxygen, nutrition, growth factors, love, and what’s called “passive immunity” via maternal antibodies. These are large molecules, a kind of immunoglobulin called “IgG” which mom had made previously after exposures to diseases or vaccines. Good maternal immunity to things like influenza and measles does provide good protection for their newborns. That’s why it’s important for pregnant women to get flu vaccines, and for all girls to get all of their vaccines—so later, when they’re pregnant, their little babies get protection, too.

But those IgGs from momma, they don’t last so long. The “titers” drop off fairly rapidly, and the protection falls quickly. Best protection probably lasts weeks, with some protection falling off over months. By six months of age, there’s probably no protection from maternal IgGs.

However, there’s still some small amount of IgGs circulating. Though they’re not protective, they can interfere with some kinds of vaccines (especially live, attenuated vaccines like MMR and chicken pox.) That’s why these vaccines are ordinarily given at 12 months of life or later. It’s not dangerous to give them early—it’s just that they probably won’t work as well to provide strong, lasting protection. Maternal IgGs do not interfere with the effectiveness of many other vaccines, like the Hepatitis B, DTaP, polio, and the other vaccines given in the first year of life.

 

Can you give MMR vaccine earlier, say if exposure risk is high?

Yes, though it may not work as well or provide protection that’s long-lasting. Current recommendations are to give the first dose of MMR routinely at 12-15 months of life. It should be given early (as early as 6 months) if the risk of exposure is high. For example, the CDC currently recommends early MMR for international travel to Europe, Asia, the Pacific, and Africa. I think it would also be prudent to vaccinate early for travel to California, especially if your baby will be in crowded places like airports or theme parks (California officials have said that these places are safe—IF you’re vaccinated.)

A dose of MMR vaccine given in the 6 – 11 month window will provide some protection, but since the lingering maternal IgGs will prevent it from being fully effective the dose doesn’t “count.” Two further doses will still be needed, following the typical schedule at 12-15 months and at 4-5 years of age.

 

Doesn’t breastfeeding give baby antibodies? Wouldn’t that prevent measles? Or can breastfeeding interfere with the MMR vaccine?

Breastmilk does contain antibodies, but they’re a different kind of antibodies. They’re not the IgG antibodies that circulate in the blood, they’re IgA antibodies that concentrate more in body secretions, including nasal mucus and breast milk. These IgA molecules don’t interfere with vaccines. They provide modest protection against mostly gastrointestinal infections (think diarrhea and vomiting illnesses)—which makes sense, because the breastmilk IgA molecules are swallowed. They don’t make their way into the blood, or at least not very much—like other proteins, if you swallow them they’re mostly torn apart during digestion. Breastmilk IgA provides just a little protection against infections that are caught via the respiratory tract, including the common cold and measles. For instance, a breastfed baby on average statistically will likely get one half of an ear infection fewer in the first year of life. Not a huge impact, at least not in respect to those kinds of infections.

 

Is there any way to test for those maternal measles IgG antibodies? I mean, if my baby’s antibodies are low enough at 9 months of age, could I get him vaccinated then?

Well, you can test for them, but the exact amount doesn’t perfectly correlate with whether the baby will become immune after the vaccine. You won’t know if the vaccine given at 9 months worked well unless you test your baby afterwards—and even then, there’s a grey zone in the measurements.

 

Maybe we should test for immunity? I mean, should we be testing children after the MMR to make sure it worked?

After one dose of MMR, about 85% of children will get complete, lifelong protection against the three components: measles, mumps, and rubella. The second dose, traditionally given at age 4-5, will pick up almost all of the remaining unprotected 15%, leaving only 1% non-immune. Those odds are really, really good—and if a community has high vaccination rates, that 1% of kids whose MMR didn’t take are still well protected by herd immunity. Of course, if vaccine rates fall, it all falls apart. The 1% who didn’t respond are vulnerable, as are babies too young to vaccinate and people with health conditions that preclude vaccination.

Testing for immunity can done under special circumstances, sometimes to help control an outbreak, or in people at risk for losing immunity after chemotherapy, for instance. But the testing is expensive and kind of a hassle (it’s not always easy to draw blood from children, and they don’t like it very much.) Because the vaccine is so safe, it makes more sense to just give the two doses than to test everyone.

Measles at Disneyland: Looking back, looking ahead

January 26, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

This past Christmas holiday, an as-yet-unindentified “index case”—the first person to start an epidemic—visited Disneyland in California. 5 employees became infected, along with dozens of visitors to the park. Since then, the outbreak has spread to about 80 people, including people who’ve caught it not directly from visiting Disney, but by coming in contact with Disney cases. These “secondary” cases will soon lead to “tertiary” cases—people who catch it from people who caught it from people who were at Disney. And on and on.

Such is the nature of epidemics, especially with a super-contagious illness like measles. We’re not talking Ebola, here—that can only spread from direct contact, touching the body fluids of someone who is dying from Ebola. No, measles spreads much more easily. Measles becomes contagious before symptoms start, and the infection can spread from the very air that someone who’s carrying measles breathes.

Fortunately, there is a very effective vaccine. With two doses, as recommended, there’s about 99% protection. That is a very effective vaccine. But in country with about 300 million people, even if 100% of us were vaccinated there would be 1%- 3 million – unprotected people. Add to that babies younger than one year, who can’t be routinely vaccinated, and people with immune deficiencies and other health problems that leave them vulnerable. Even if everyone who could get vaccinated got vaccinated, there would still be some vulnerable people. But we know that if just about everyone does get vaccinated, those vulnerable people are protected by “herd immunity”—with very little circulating measles, everyone is protected.

But what happens when people decide not to vaccinate? And what if a lot of those people live in the same neighborhoods and counties? We knew what would happen. It’s been an entirely predictable and avoidable catastrophe: a measles outbreak.

In the latest news, USA Today has been focusing on the spread of the epidemic, which has now extended outside of California into 4 more western states and Mexico. They also report that several California schools have sent dozens of unvaccinated children home to contain the spread of measles, including 24 students from Huntington Beach High School. CBS news has pointed out just how contagious measles is, and why this could end up being the beginning of a really huge outbreak.

Many reporters are drawing attention to the role of unvaccinated children in the spread of this epidemic. Almost all of the cases reported have been in unvaccinated children, including some babies too young to be vaccinated and many children whose parents chose to not get them vaccinated. A Washington Post blogger has illustrated the resurgence of measles from non-vaccination, all in one chart. At least one mom is mad that her child was singled out to stay home because she hadn’t been vaccinated for medical reasons—though, in fact, having a brother who had a severe reaction to a vaccine is not a contraindication to vaccinating a sibling. There is no “family tendency” that changes the estimated 1 in a million risk of a serious vaccine reaction.

The national media hasn’t focused on this much, but the State of California has declared that theme parks, airports, and other public places are not safe for people vulnerable to measles. That includes anyone who hasn’t been immunized—not just kids of non-vaccinating parents, but babies and people with immune problems. That’s right—the State of California now officially recommends that babies not go to airports. It’s not safe. Want to take your 9 month old to visit Grandma in Atlanta? You’d better drive. And don’t think about taking your baby to Disney in California—Disney says their parks are perfectly safe for vaccinated people, implying that babies and others who are unvaccinated should stay away.

The international community has jumped on board, too. From Canada, a report points out the double-digit vaccine exemption rates in some California school districts, quoting a public health official, “When our immunity falls, it creates a problem for the whole community.” They also reached out for a quote from longtime anti-vaccine activist Barbara Loe Fisher, of the misleadingly named “National Vaccine Information Center.” (In all honestly, the “National Antivaccine Lies and Propaganda Center” would be a more-fitting name.) Fisher illustrates her difficulties with understanding fractions by pointing out that a small number of people who’ve caught measles were vaccinated. Yes, but in an area where 90%+ overall are vaccinated, that almost all of the cases were unvaccinated tells you something about disease transmission.

Overseas, the BBC drew attention to one specific Orange County pediatrician, Dr. Bob Sears. Right in the heart of Orange County, home of Disneyland, Dr. Bob has been a longstanding supporter of non-vaccination—about half of his patients are unvaccinated. In some Orange County schools, 60% of children have a “personal belief exemption” so they can attend school without vaccines. The article quotes a professor who compares vaccine-denying parents to a drunk driver “who makes a socially irresponsible decision that can endanger not only his life, but also the lives of the other drivers and passengers on the road.”

Dr. Bob has responded to his critics, first in an odd, rambling Facebook post that tried to show that measles was nothing to worry about (though he admitted it could be serious for babies and immunocompromised people—but, apparently, we don’t need to be concerned about them.) He then petulantly responded to critics by calling them “stupid.” Classy, Dr. Bob.

I’m heartened to see that many media outlets have really come down hard on the so-called “anti vaccine movement,” with headlines like “Measles is horrible and is yet another thing the anti-vaccine movement is wrong about”. Yet some outlets are still posing this as a rhetorical question, like Yahoo’s “Is the anti-vaccination movement to blame for Disneyland’s measles outbreak?” Yes, Yahoo, it is.

As often happens, some of the best, in depth material about the outbreak has been coming from bloggers. Over at Science Based Medicine, Dr. David Gorski has covered the outbreak in detail (don’t miss the comments—a lot of great insight there too). He also illustrates the contributions of nincompoop anti-vaccine doctors like Dr. Jay Gordon, also of (you guessed it) California. Other superb blogs about the issue have appeared at the similarly-minded Respectful Insolence here and here. Chad Hayes, MD, at his eponymous blog, approached this from a different angle in his piece “Dear anti-vax parents: We’re not mad at you.” Dr. Hayes is right—and that sometimes gets lost in the media swirl. It’s not the parents we’re mad at. It’s the people spreading lies, fear, and misinformation. Parents are caught in the middle, unsure who to trust, filled with worry. That’s a shame. Parents have been tricked into worrying about the vaccines, when it’s the diseases that cause the problems.

A lot of anti-vaccine (mis)information continues to appear. At least one Arizona doctor (an “integrative cardiologist,” whatever that is) proudly and clearly says “Don’t vaccinate your kids”—at least he’s not being a weasel about this. Let it all hang out, Doc! And many mainstream reporters still seek out the usual few anti-vaccine docs for quotes in otherwise fact-filled articles, like this one from USA Today. There, Dr. Jay tells us that while there’s “no proof the vaccine is dangerous… It’s not a crucial shot.” In a New York Times piece, that same doc incoherently says: “I think whatever risk there is — and I can’t prove a risk — is, I think, caused by the timing. It’s given at a time when kids are more susceptible to environmental impact. Don’t get me wrong; I have no proof that this vaccine causes harm. I just have anecdotal reports from parents who are convinced that their children were harmed by the vaccine.” I think now is the time for reporters to stop going out of their way to quote these dangerous idiots.

I’ve saved the best for last—the parody sites, who’ve found this outbreak a rich source of terrific articles. What makes them so effective is that they all rely on that germ of truth. From The Onion, “Diphtheria excited about possibility of new outbreak”, and “I don’t vaccinate my child because it’s my right to decide what eliminated diseases come roaring back.” They’ve also got some great “quotes”, here and here, including the deliciously ironic “To be fair to the parents, no one could have predicted that neglecting to immunize people against diseases would lead to more people getting diseases.” Over at The Washington Post, an article that may have been written by A. Measles Virus is titled “Please stop vaccinating your children. I want to go to Disneyland.”

In all seriousness, this is just the beginning of an outbreak that could really be a catastrophe. Hundreds of thousands of public health dollars are being spent—and soon it will be millions. Parents and babies and children are missing weeks of school and work. Dozens of people are sick, and about a quarter of measles cases so far have had to be hospitalized. This really isn’t a joke at all. Hopefully, though, it will be a turning point. For those of you who still support and encourage parents not to vaccinate, now is the time to rethink your message. It’s time to end the “controversy” that never really existed. Vaccines are safe and effective, and we need to work together to protect all of us, including the most vulnerable.

“Until this moment… I think I have never gauged your cruelty or your recklessness. … You have done enough. Have you no sense of decency?”

 

 

A vaccine triumph!

November 15, 2010

The Pediatric Insider

© 2010 Roy Benaroch, MD

For the second time in human history, a vaccine has helped successfully eradicate a terrible disease from the face of the earth.

Rinderpest, caused by a virus in the measles family, has never infected humans. But it kills about 80% of its victims, mostly livestock like cattle and oxen. It has caused the loss of entire herds, and has led to human famine in Africa and Europe. An effective, reliable vaccine was developed in the 1950’s, and coordinated efforts including tracking, quarantine, and vaccination led to a quick decline of this devastating illness. The UN has announced that the last case or rinderpest transmission was in 2001, and at this time the disease has been declared completely eliminated from natural transmission.

Smallpox, a much-deadlier cousin of chicken pox, was eradicated as a cause of human disease in the 1970’s. And Guinea Worm, which once caused misery and debility to millions of people in central Africa, may also soon be a disease only seen in the history book.

Other diseases could at least theoretically be eliminated entirely. Measles, for instance, is genetically stable, only carried by humans, and has a very safe and effective vaccine. Poliomyelitis was almost eliminated several years ago, until warlords in Africa used violence and anti-vaccine propaganda to destroy years of coordinated efforts.

Let’s give credit where credit is due: vaccines, along with other public health measures, have been tremendously successful in improving and extending our lives. As part of a coordinated attack, they can even completely eliminate diseases from the face of the Earth. We’re all in this together. Make sure your child is up-to-date on the vaccines that are protecting us all.