ResearchBlogging.orgIt seems like every time I take Huxley (now 18 months old) to the doctor, the following things happen: 1) Somebody says “Well, he won’t need to get stuck with any needles for a long while now …. his next scheduled immunization is [insert phrase indicating ‘a long time into the future’]”; and 2) Huxley gets stuck with some needles.

The last time, a few days ago, was especially bad.

[A repost in honor of Get Your Damn Flu Vaccine Week]

We hung around in the exam room for a while, and Huxley was in a very happy mood. He learned to say “Elmo” and how to point to the “Otoscope” when asked. The doctor, having recently had a baby of her own, had not seen him in a long time, and they were happy to see each other and got along just fine. The examination showed no problems. The doctor left happy with Huxley’s progress.

Then, the inoculations nurse walked in.

“You hold his arms and I’ll get his feet.”

Huxley was shocked and surprised when the first needle went in.

His eyes belied an expression of betrayal and fear when the second needle when in.

He turned red and his lower lip started to quiver when the third needle went in.

The redness deepened considerably and tears started to stream down his cheeks when the fourth needle went in.

He started to wail when the fifth needle went in.

He gave me a distinctly dirty look when the sixth needle went in.

And then he did something he’s done every time he’s gotten a vaccination: He did not die.

I’ve seen babys die. Have you? Babies tend to die quietly. They are not red-faced and teared-up and lip-quivering and crying loudly. Rather, they are quite, lethargic, limp, droopy-eyed, and then, just lifeless. Or at least, that is what I’ve seen. That’s what a baby looks like after days or weeks of being ravaged by an infectious disease that finally kills it. Typically, the mother looks only a little bit better, and is almost as silent.

Huxley was pretty brave through his first four vaccines, but the last two got to him. Normally, there would have been only four shots, but the state health authorities decided to move an MMR shot he would have gotten later (and thus, another shot that goes nicely with MMR) to an earlier time to help stem an outbreak of measles going on in Minnesota right now.

Situation Update (4/27/11)
There have been 23 confirmed cases of measles reported in Minnesota, ranging in age from 4 months to 51 years old.
Infection acquired:

Twenty of the cases have been linked to a case that acquired infection in Kenya (21 total)
One case acquired infection in Florida
One case acquired infection in India

Vaccination status:

Seven of the cases were too young to receive vaccine
Nine were of age but were not vaccinated
One was vaccinated
One was vaccinated prior to the recommended age
Five have unknown vaccine status

There have been fourteen hospitalizations and no deaths.

source

Most children in the US who have not been vaccinated are the victims of parents who refused the vaccine out of ignorance. As you know, there is a strong anti-vax movement in the US. They think vaccinations cause all sorts of problems, including autism. Or, perhaps they just think that vaccinations are just unnatural.

But I’m pretty sure some anti-vaxers … not the activists but just some of the parents who quietly chose to not have their children stuck … do so because they can’t stand the needle, the pain, and (in some cases) the subsequent though generally very minor suffering or discomfort of a needle-wound or side effects of the vaccination. And I can understand that. When you see the infant you love being so brave in the face of the atrocities of the doctor’s office, turning red, trying not to cry, lip quivering, finally breaking down, and that look … that look of betrayal … Yeah, I can see not wanting to do this too often.

But I do get Huxley vaccinated because 1) I’m not some kind of selfish moron who wants to avoid personal discomfort or self-blame for an infant’s short-lived pain and b) I’ve seen the babies die, quietly at the end though often after days or weeks of very obvious pain and suffering, of infectious diseases. So when I watched Huxley take his shots like the man-infant he is, I simply reminded myself that this was better than an untimely burial, but I did let myself get a little mad at the Anti-Vaxers who, through their ignorance and hatred of other people’s children, caused the MMR schedule to change and Huxley to endure two more shots in one sitting than usual.

We don’t know where the current Minnesota outbreak is going, but there was an outbreak of measles in 2008 that has been studied in a recent paper called “Health Care-Associated Measles Outbreak in the United States After an Importation: Challenges and Economic Impact” by Sanny Chen et. al.

From the abstract:

On 12 February 2008, an infected Swiss traveler visited hospital A in Tucson, Arizona, and initiated a predominantly health care-associated measles outbreak involving 14 cases. … Of 14 patients with confirmed cases, 7 (50%) were aged ≥18 years, 4 (29%) were hospitalized, 7 (50%) acquired measles in health care settings, and all (100%) were unvaccinated or had unknown vaccination status. Of the 11 patients (79%) who had accessed health care services while infectious, 1 (9%) was masked and isolated promptly after rash onset. HCP (Health care personnel) measles immunity data from 2 hospitals confirmed that 1776 (25%) of 7195 HCP lacked evidence of measles immunity. Among these HCPs, 139 (9%) of 1583 tested seronegative for measles immunoglobulin G, including 1 person who acquired measles. The 2 hospitals spent $799,136 responding to and containing 7 cases in these facilities.

Suspecting measles as a diagnosis, instituting immediate airborne isolation, and ensuring rapidly retrievable measles immunity records for HCPs are paramount in preventing health care-associated spread and in minimizing hospital outbreak-response costs.

Measles infected between 3 and 4 million Americans a year before vaccines stemmed the disease in the early 1960s. Between 2000 and 2008, between 37 and 140 cases were reported annually in the US. The typical pattern is for an imported case of measles to cause a local outbreak among unvaccinated people. Those unvaccinated people are almost always of two kinds: Those who are not vaccinated because of the Anti-vax movement, or those who were too young to be vaccinated (or who are unvaccinated for some other equally valid reason) and are thus victims of the anti-vaxers.

The study points out that because measles is such a nasty disease, those infected often end up in a health care facility. For this reason, health care professionals have a higher risk of acquiring the disease. The other group at higher risk for getting measles is, of course, patients in the health care facility. Take Patient 4 from the Tucson outbreak:

Patient 4 was an unvaccinated 11-month-old boy who had spent 45 min in an ED room across the hall from patient 2 at hospital A on 24 February. Fever (temperature, 38.9°C) developed on 4 March, and a maculopapular rash developed on 10 March.

And some of those at risk are at risk because their parents chose to put their children at risk:

Patients 5 and 6 were siblings aged 3 and 5 years, respectively, who had not been vaccinated because of parental opposition to vaccination. Both children were exposed to patient 2 while visiting their mother at hospital A on 24 and 25 February. Their fever onsets occurred on 5 March (temperature, 39.5°C) and 6 March (38.9°C), respectively.

And, these accidental accomplices can then put others at risk in a kind of vicious cycle. Consider, for example, Patient 8:

Patient 8 was an unvaccinated 1-year-old girl who was exposed to patient 4 in the pediatrician’s office on 10 March while waiting to receive MMR vaccine. Fever (temperature, 38.5°C) developed on 19 March, a generalized maculopapular rash developed on 20 March, and earache developed on 20 March.

It turns out that in Minnesota, the current outbreak is facilitated in part by misinformation being spread among certain fairly recent immigrants. After arrival in the US, they were indoctrinated into the anti-vax ideology by someone. I’m not sure how this happened exactly, but apparently members of the Somali community are concerned that anti-vax misinformation has been circulated and is causing many individuals to avoid vaccinations. This is being addressed.

In the mean time, get your vaccination and get your children vaccinated.

Chen, S., Anderson, S., Kutty, P., Lugo, F., McDonald, M., Rota, P., Ortega-Sanchez, I., Komatsu, K., Armstrong, G., Sunenshine, R., & Seward, J. (2011). Health Care-Associated Measles Outbreak in the United States After an Importation: Challenges and Economic Impact Journal of Infectious Diseases DOI: 10.1093/infdis/jir115

Comments

  1. #1 Rob Whelan
    September 27, 2011

    My 2-year-old has had all the normal vaccines at the normal times, because although she (and my wife and I as well) dislike the needles, we’re not stupid.

    But *six* needles? Of which four are standard?

    Maybe we just have a great pediatrician, or maybe things are different here in France (country-side standard vax schedule = standardized blends of vaccines?), but when it’s time for a vaccination, not only has there never been more than a single needle, we also always get a patch (EMLA Patch) to put on her leg in advance so she doesn’t even feel the (single) needle prick on her skin.

    There are no strangers holding her down, either; she’s in my arms, we hold still for the few seconds of the shot, then we jump around the office together to help her feel better.

    Now that she’s old enough that we can talk about the whole process, at the most recent one she fussed for about 3 seconds, then we went back to talking about ice cream. Tear-free.

    Sorry to ramble on, but the image of holding down a child and poking them with half a dozen needles seemed like one of those things out of an anti-vaxxer propaganda film. It’s at least somewhat traumatic for the child and parents, and if it’s not necessary (and every child could have a vaccination experience like my daughter is having) that’s quite simply a bad thing.

  2. #2 Calli Arcale
    September 27, 2011

    After arrival in the US, they were indoctrinated into the anti-vax ideology by someone.

    I’m sure it didn’t start with him, but one of the people who spoke to the Minnesota Somali community was none other than Andrew Wakefield, under the banner of autism awareness, which is a relatively new bogeyman for them. (Autism isn’t new to that gene pool, but the name and diagnosis are certainly new. It would be to lie by understatement to say that mental health care in Somalia is substandard.) Fortunately, Somalis are not stupid, and their culture traditionally favors widespread education, including of girls. It hasn’t taken long for the community to realize the score, and some of them are very angry at the anti-vaxxers.

  3. #3 Greg Laden
    September 27, 2011

    Rob, things are different in France. Generally, there are fewer vaccinations in Europe.

    (and every child could have a vaccination experience like my daughter is having) that’s quite simply a bad thing.

    Nope. Many of the measles outbreaks,for instance, that occur in the US are from Europeans coming from countries where there is less vaccination.

    Please don’t assume that just because US usually gets everything wrong and Europe usually gets everything right that we are doing it wrong. Most European countries will have to shift to more vaccines in coming years.

  4. #4 Rob Whelan
    September 27, 2011

    Hi, Greg; thanks for the response! No, I’m not generally full of praise for the enlightened Europeans. As my wife & I have entered parenthood, we’ve discovered to our deep chagrin that the parents who share our interest in breastfeeding, co-sleeping, non-violent parenting, avoiding filling the house with TVs & plastic junk, etc. are ALSO extremely likely to start telling us about homeopathic alternatives to vaccines, bizarre ways to “remove toxins”, and so on….

    For vaccinations — it’s possible the French schedule is a bit less dense than US requirements; I know my daughter’s getting a couple I didn’t as a child, but that doesn’t say much. Here’s the schedule via Google Translate:
    http://translate.google.com/translate?u=http%3A%2F%2Fvosdroits.service-public.fr%2FF724.xhtml
    It does indeed include measles — though looking at it, now I wonder if my memory of never-multiple-shots is wrong, or if we simply spaced them out a bit more (i.e., getting month 4 shots at month 4 and 5)… I’m thinking the memory must not be quite right in those early months.

    I still think it’s worth the effort to improve the experience as much as possible — like the anesthetic patch, like avoiding holding the child down on a table, like using combo shots as much as possible. I imagine there are some vaccines that can’t be mixed… but if they can be, well, ask for that one. Were none of those 6 shots available together? Or was it just simpler for the clinic to track the individual versions?

    I’d suspect the latter — medicine tends to go in this direction unless someone pushes back. The toddlers can’t; and parents generally don’t remember how unpleasant physical coercion coupled with pain is (I had a childhood with extra needles for medical reasons, unfortunately; I remember).

    Except for the parents who object, and do a bit of “research”, and then find the anti-vaxxers telling them exactly what they want to hear. Blargh. So anyway, for anyone willing to push back a bit to improve the experience, that’s good for everyone.

  5. #5 Doug Kennedy
    September 28, 2011

    Hi Greg, I wonder if it would be easier on the little ones to go in and only get one or two needles at a shot. Give the immune system a little less stress, still get the AB system going, and avoid systemic-overwhelm. (I have two kids, quite grown up now, and HATED going to get the shots)…and when I get my annual Flu shot, I take 1/2 a vial and then a few days later take the other 1/2 (when they let me).
    Doug
    ps I enjoy your anti-TeaBagger attitude…what is WRONG with the mentality of some of these people?

    I vacationed in S Carolina this summer: didn’t see anybody that was a Local that wasn’t underweight. Or normal BMI for that matter. Lot’s of fried food, obesity, diet soda, and hardly any veggies in the grocery carts at the supermarkets.

    But then when the diabetes shows up (surprise!) they want help with the medicine, and the hypertension meds, and on and on. Some things should be legislated.

  6. #6 Ender
    September 28, 2011

    “Hi Greg, I wonder if it would be easier on the little ones to go in and only get one or two needles at a shot.”

    Nothing wrong with that. Harder to book more appointments and less efficient for the doctor but it’s not about them.

    “Give the immune system a little less stress, still get the AB system going, and avoid systemic-overwhelm”

    I wouldn’t worry about the immune system being stressed, a child encounters more antigens every day than are in all these vaccines and their immune system does fine. Systemic-overwhelm isn’t a thing either (re: vaccines at least) so you don’t have to worry about that either.

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