October 28, 2020

REBEL Core Cast 43.0 – Measles + Antivax

Take Home Points

  • Measles is highly infective: One infected person can infect approximately 10-20 unvaccinated people
  • 2 doses of MMR is 97% protective
  • Unvaccinated people can acquire measles from travel to endemic areas with low vaccination rates
  • There is a large amount of misinformation on the internet
  • Misinformation uses fear based messaging and the power of story
  • The evidence is overwhelming > 23,000,000 patients showing no evidence of any link between autism and MMR
  • Anecdotes are not evidence but vulnerable patients may be more susceptible to story then statistics
  • We should add anecdote as a tool to counsel patients

REBEL Core Cast 43.0 – Measles + Antivax

Measles Review:

  • R 9-18:  One infected person can infect approximately 10-20 unvaccinated people
  • Transmitted via respiratory droplets
  • Aerosolized viral particles remain in the air for 2 hours
  • Exposed people who are not immune have a 90% chance at becoming infected
  • Incubation period of 10-14d from the day of first exposure
  • Patients are contagious 4 days before classic rash and 4 days after onset of rash (approximately 8 days total)
  • Patients can shed the virus before we can distinguish the illness a typical viral syndrome
  • Classic features are cough, coryza, conjunctivitis, maculo-papular rash
  • Rash spreads from head to trunk and extremities and resolves the same way
  • Koplick spots are grayish blue lesions on the oral mucous which are present in 70% are pathognomonic

Measles Epidemiology and New Outbreaks:

  • We can prevent and eradicate measles
    • 2 doses of MMR is 97% protective
    • Easily diagnosable clinical syndrome
    • No animal reservoir
  • Vaccine first licensed in 1963 and measles rapidly declined
  • Prior to immunization estimated 2-3 million deaths globally per year
  • Still leading cause of vaccine preventable death (>100,000 deaths/year globally)
  • Requires 90-95% vaccine coverage to maintain herd immunity
  • In 2000 US eradicated measles with high vaccine coverage
    • (no sustained transmission of virus for more than 12 months)
  • Estimated 21 million deaths prevented worldwide since 2000 due to vaccination
  • Rise in new measles outbreaks (31% increase from 2016 and 2017)
  • 704 cases since January 2019 (Largest number since measles declared eradicated)
  • 13 outbreaks involving 22 states
  • 503 of 704 (71%) were unvaccinated
  • 6 of 13 were close knit non-immunized communities
  • Unvaccinated people can acquire measles from travel to endemic areas with low vaccination rates
  • Outbreaks driven by vaccine misinformation

Anti-Vaccine movement:

  • 1998 Lancet case series of 12 patients reported enterocolitis linked to regressive autism triggered by MMR vaccine
  • Patients were recruited through anti-MMR campaigners
  • Study commissioned and funded with plan for lawsuit against pharmaceutic companies
  • Data was manipulated and falsified to fit this narrative to support the lawsuit
  • Article was retracted and the principle author lost his license
  • BUT THE DAMAGE WAS DONE

Internet and Social Media Evidence:

  • Youtube videos about immunizations: 32% opposed vaccinations
    • Anti vaccination videos had higher ratings and more views than pro-vaccine videos
  • Google search study: Analyzed content of the first 100 sites found after typing in “vaccination” and “immunization” Into Google
    • 43% of the websites were anti-vaccination
  • Twitter study: 50% of tweets about vaccination contain anti-vaccine beliefs
  • Celebrities and elected public official use social media to spread misinformation about vaccines
    • Vulnerable people believe their status gives them access to information the average person might not have
  • Parents link autism and other diseases to “vaccine injury”
    • Share stories on anti-vaccine blogs and discussion boards to “warn” other parents
  • Stoke fear in parents that vaccines are dangerous without accurate info to refute claims
  • Article in Vaccine in 2008: 5-10 minutes on anti-vaccine site can increase perceptions of vaccine risks and decrease perceptions of risks of avoiding vaccines
    • perceptions persisted 5 months later
    • children of these parents receive less vaccines

Non-medical exemption (NME):

  • 18 states allow for non medical exemptions
  • High number of NMEs in some densely populated areas (Washington, texas)
  • Vaccine preventable diseases could originate and spread rapidly through these areas
  • A child with NME for MMR is 35x more likely to contract measles
  • NMEs weaken herd immunity

What are parents’ concerns?

  • Vaccine 2007
    • oversights
    • socioeconomic barriers: low income, multiple children
    • health care may be divided across providers
    • Religious or personal exemptions
    • Medical exemptions
  • Some Anti Vaccine beliefs
    • Children receive too many vaccines in total
    • Children receive too many vaccines at one time
    • Vaccines are unsafe
    • Vaccines have long term negative health effects
  • Vulnerable parents seek additional information
    • May use the Internet rather than ask their doctor
    • Searches led to both public health and anti-vaccination sites

Evidence Based Medicine:

  • Meta analysis Vaccine in 2014
    • more than 1.2 million patients
    • no evidence for association between autism, ASD and vaccination or any components such as thimersol or mercury
  • 2019: ANNALS OF INTERNAL MEDICINE:
    • 6517 cases and 650,000 patients
    • Largest single study ever conducted
    • More than 5,000,000 person years of follow up
    • Repeat of similar study by same group which did not overlap with another >500,000 patients
    • No evidence of increased risk of autism after MMR vaccine
    • No evidence MMR triggers autism in susceptible subgroups
    • No evidence for clustering of of cases in specific time periods —> autism overnight
  • This Cochrane Review was published in April of 2020
    • Included 138 studies (23,480,668 participants)
    • Vaccines did not cause autism or any other suspected unwanted effect.
    • Small risks of febrile seizures and ITP

Counseling Patients on misinformation

  • Anti-vaccination movement has a better and more compelling story
  • Medical websites, statistics, vaccine fact sheet may not be enough
  • Stories can make information easily understandable for patients
  • Stories penetrate more deeply then just numbers and stats
    • Use clinical experience where we care for patients with these vaccine preventable diseases
    • Many doctors are parents face the same vaccine decisions
    • highlight the reasons we chose to vaccinate
  • Vaccine ambassadors: other parents who vaccinate
  • Pro-vaccine blogs for those who prefer this type of info
  • Presentation Zen: don’t leave the numbers hanging
  • Use numbers in a way parents can understand
  • For example Instead of percentages… maybe more effective to say one child in you kids class will be affected by this disease
  • RESONATE: “Greatest stories of all time are packaged and transferred so well that hundred of illiterate generations could repeat them”
  • Hero’s journey: “You are not the hero” in this story the parents are the hero
  • We are mentors along the way
  • How to win friends and influence people:
    • Remember that a person’s name is to that person the sweetest and most important sound in any language.
    • Make the other person feel important – and do it sincerely
    • Give them a fine reputation to live up to
    • Be a good listener and encourage people to talk about themselves
    • Be sympathetic with the other person’s ideas and desires
    • Get the other person saying ‘yes, yes’ immediately.”
    • Any fool can criticize, complain, and condemn—and most fools do. But it takes character and self-control to be understanding and forgiving.

References:

  1. Paules CI, Marston HD, Fauci AS. Measles in 2019 – Going Backward. N Engl J Med. 2019;380(23):2185-2187.
  2. Patel M, Lee AD, Redd SB, et al. Increase in Measles Cases – United States, January 1-April 26, 2019. MMWR Morb Mortal Wkly Rep. 2019;68(17):402-404. Published 2019 May 3.
  3. Carlson A, Riethman M, Gasta̱aduy P, et al. Notes from the Field: Community Outbreak of Measles РClark County, Washington, 2018-2019. MMWR Morb Mortal Wkly Rep. 2019;68(19):446-447. Published 2019 May 17.
  4. McDonald R, Ruppert PS, Souto M, et al. Notes from the Field: Measles Outbreaks from Imported Cases in Orthodox Jewish Communities – New York and New Jersey, 2018-2019. MMWR Morb Mortal Wkly Rep. 2019;68(19):444-445. Published 2019 May 17.
  5. Hussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018;10(7):e2919. Published 2018 Jul
  6. Benecke O, DeYoung SE. Anti-Vaccine Decision-Making and Measles Resurgence in the United States. Glob Pediatr Health. 2019;6:2333794X19862949. Published 2019 Jul 24.
  7. Keelan J, Pavri-Garcia V, Tomlinson G, Wilson K. YouTube as a source of information on immunization: a content analysis. JAMA. 2007;298(21):2482-2484. doi:10.1001/jama.298.21.2482
  8. Davies P, Chapman S, Leask J. Antivaccination activists on the world wide web. Arch Dis Child. 2002;87(1):22-25. doi:10.1136/adc.87.1.22
  9. Hussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018;10(7):e2919. Published 2018 Jul 3.
  10. Benecke O, DeYoung SE. Anti-Vaccine Decision-Making and Measles Resurgence in the United States. Glob Pediatr Health. 2019;6:2333794X19862949. Published 2019 Jul 24. 
  11. Betsch C, Renkewitz F, Betsch T, Ulshöfer C. The influence of vaccine-critical websites on perceiving vaccination risks. J Health Psychol. 2010;15(3):446-455. doi:10.1177/1359105309353647
  12. Downs JS, de Bruin WB, Fischhoff B. Parents’ vaccination comprehension and decisions. Vaccine. 2008;26(12):1595-1607. doi:10.1016/j.vaccine.2008.01.011
  13. Olive JK, Hotez PJ, Damania A, Nolan MS. The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties [published correction appears in PLoS Med. 2018 Jul 6;15(7):e1002616]. PLoS Med. 2018;15(6):e1002578. Published 2018 Jun 12.
  14. Strebel PM, Orenstein WA. Measles. N Engl J Med. 2019;381(4):349-357. doi:10.1056/NEJMcp1905181
  15. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32(29):3623-3629. doi:10.1016/j.vaccine.2014.04.085
  16. Hviid A, Hansen JV, Frisch M, Melbye M. Measles, Mumps, Rubella Vaccination and Autism. Ann Intern Med. 2019;171(5):388. doi:10.7326/L1-0383
  17. Di Pietrantonj C, Rivetti A, Marchione P, Debalini MG, Demicheli V. Vaccines for measles, mumps, rubella, and varicella in children. Cochrane Database Syst Rev. 2020;4(4):CD004407. Published 2020 Apr 20. doi:10.1002/14651858.CD004407.pub4
  18. Shelby A, Ernst K. Story and science: how providers and parents can utilize storytelling to combat anti-vaccine misinformation. Hum Vaccin Immunother. 2013;9(8):1795-1801.
  19. Reynolds, Garr. Presentation Zen : Simple Ideas on Presentation Design and Delivery. Berkeley, CA: New Riders, 2012.
  20. Carnegie, Dale, 1888-1955. How To Win Friends and Influence People. New York: Simon & Schuster, 2009.
  21. Duarte, Nancy. Resonate. Hoboken, NJ. 2010

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 43.0 – Measles + Antivax", REBEL EM blog, October 28, 2020. Available at: https://rebelem.com/rebel-core-cast-43-0-measles-antivax/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author

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