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We’re Ignoring the Biggest Cause of the Measles Crisis We’re Ignoring the Biggest Cause of the Measles Crisis
(about 16 hours later)
In September, New York City declared that its latest measles outbreak was over. More than 60 percent of the 650 people who contracted the illness were children under 5, those most susceptible to a severe measles illness.In September, New York City declared that its latest measles outbreak was over. More than 60 percent of the 650 people who contracted the illness were children under 5, those most susceptible to a severe measles illness.
To prevent future outbreaks, we have to figure out what caused the last one. The problem is that we are misdirecting our attention. Much of it is focused on the global anti-vaccine movement.To prevent future outbreaks, we have to figure out what caused the last one. The problem is that we are misdirecting our attention. Much of it is focused on the global anti-vaccine movement.
But there is a much larger group: the “vaccine hesitant.” These people intentionally delay or deviate from the routine schedule, staggering vaccine administration according to their own timeline. This leaves children without adequate protection from preventable diseases and puts their community at risk for outbreaks. And it’s unscientific.But there is a much larger group: the “vaccine hesitant.” These people intentionally delay or deviate from the routine schedule, staggering vaccine administration according to their own timeline. This leaves children without adequate protection from preventable diseases and puts their community at risk for outbreaks. And it’s unscientific.
A committee of experts known as the Advisory Committee on Immunization Practices annually recommends an evidence-based schedule for every vaccination to the Centers for Disease Control and Prevention. No other schedule for any vaccine provides better safety or efficacy. (For measles, it’s one shot when the baby is around 12 to 15 months old and another shot at 4 to 6 years.) A committee of experts known as the Advisory Committee on Immunization Practices annually recommends an evidence-based schedule for every vaccination to the Centers for Disease Control and Prevention. No other schedule for any vaccine provides better safety or efficacy. (For measles, it’s one shot when the baby is around 12 to 15 months old and another shot at 4 to 6 years. If there is an outbreak, infants who live in that area should get a shot starting at 6 months and then continue with the standard regimen.)
Despite this, 25 percent of infants in New York have not been fully vaccinated by the time they reach 9 months. This vaccine-hesitant cohort is significantly larger than “vaccine refusers,” which is estimated to be 3 percent.Despite this, 25 percent of infants in New York have not been fully vaccinated by the time they reach 9 months. This vaccine-hesitant cohort is significantly larger than “vaccine refusers,” which is estimated to be 3 percent.
Recently, I helped care for a hospitalized 14-month-old with a bacterial blood and lung infection that a vaccine could have prevented. Several months earlier, this child also had measles, which weakens the immune system. So it was not surprising that this child had developed a subsequent severe infection.Recently, I helped care for a hospitalized 14-month-old with a bacterial blood and lung infection that a vaccine could have prevented. Several months earlier, this child also had measles, which weakens the immune system. So it was not surprising that this child had developed a subsequent severe infection.
As a pediatric infectious diseases physician, this frustrates me. The parents insisted they were not anti-vaxxers, so I went to their pediatrician’s office in the Orthodox Jewish community in Brooklyn where the outbreak was centered. I assumed their doctor was to blame. I was wrong.As a pediatric infectious diseases physician, this frustrates me. The parents insisted they were not anti-vaxxers, so I went to their pediatrician’s office in the Orthodox Jewish community in Brooklyn where the outbreak was centered. I assumed their doctor was to blame. I was wrong.
He and the five other pediatricians I interviewed in that community explained that the parents think their children will become fussier children if they receive more than one vaccine per visit. They also expressed concern about the scientifically unfounded notion that more than one vaccine at a time can burden a child’s immune system. These pediatricians reported that nearly all the families that they treat prefer to make their own vaccination schedule.He and the five other pediatricians I interviewed in that community explained that the parents think their children will become fussier children if they receive more than one vaccine per visit. They also expressed concern about the scientifically unfounded notion that more than one vaccine at a time can burden a child’s immune system. These pediatricians reported that nearly all the families that they treat prefer to make their own vaccination schedule.
In retrospect, none of the children I treated in the hospital for measles over the past year had completely abstained from vaccinations. Instead, they were undervaccinated because of their parents’ preferences.In retrospect, none of the children I treated in the hospital for measles over the past year had completely abstained from vaccinations. Instead, they were undervaccinated because of their parents’ preferences.
My initial perception of the cause of the 2018-19 measles outbreak was wrong. Parents who deviated from the immunization schedule recommended by the advisory committee and create their own had fueled the fans of contagion in what could have otherwise been a handful of measles cases.My initial perception of the cause of the 2018-19 measles outbreak was wrong. Parents who deviated from the immunization schedule recommended by the advisory committee and create their own had fueled the fans of contagion in what could have otherwise been a handful of measles cases.
All clinicians should be required to support the advisory committee’s recommended vaccine schedule for children and adults. Proper vaccination prevents an estimated 42,000 deaths over the lifetime of each American birth cohort.All clinicians should be required to support the advisory committee’s recommended vaccine schedule for children and adults. Proper vaccination prevents an estimated 42,000 deaths over the lifetime of each American birth cohort.
Yet pediatricians can face substantial resistance from families, which is compounded by the day-to-day realities of medical practice. The pediatricians I interviewed treated 50 or more patients in a day, and it takes a lot of non-reimbursed time to explain why all children need timely immunizations. The mothers prefer more frequent pediatrician visits instead of multiple shots in a single day — and doctors value their own reputation for flexibility.Yet pediatricians can face substantial resistance from families, which is compounded by the day-to-day realities of medical practice. The pediatricians I interviewed treated 50 or more patients in a day, and it takes a lot of non-reimbursed time to explain why all children need timely immunizations. The mothers prefer more frequent pediatrician visits instead of multiple shots in a single day — and doctors value their own reputation for flexibility.
Ending this recent measles outbreak required partnerships among doctors, public health officials and communities. More than 33,000 doses of measles, mumps and rubella vaccine were administered to New York City residents, providing the herd immunity that slowed and ultimately stopped the chain of spread.Ending this recent measles outbreak required partnerships among doctors, public health officials and communities. More than 33,000 doses of measles, mumps and rubella vaccine were administered to New York City residents, providing the herd immunity that slowed and ultimately stopped the chain of spread.
We need policy solutions to support pediatricians and protect vulnerable children by preventing outbreaks. In addition to countering the vocal anti-vaccine movement, our public health initiatives need to emphasize the dangers of vaccine delay. Personalized, untested vaccine schedules are tantamount to another outbreak across all socioeconomic populations.We need policy solutions to support pediatricians and protect vulnerable children by preventing outbreaks. In addition to countering the vocal anti-vaccine movement, our public health initiatives need to emphasize the dangers of vaccine delay. Personalized, untested vaccine schedules are tantamount to another outbreak across all socioeconomic populations.
The New York City Department of Health and Mental Hygiene monitors whether doctors stick to the advisory committee’s recommended vaccination schedule. This information should be made public and patients should have easy access to it. Financial incentives and penalties can alter health outcomes and should be applied to vaccine timeliness.The New York City Department of Health and Mental Hygiene monitors whether doctors stick to the advisory committee’s recommended vaccination schedule. This information should be made public and patients should have easy access to it. Financial incentives and penalties can alter health outcomes and should be applied to vaccine timeliness.
Medical practices or clinics with the highest rates of adherence to the federal immunization schedule should receive additional compensation from Medicaid, Vaccines for Children and other government programs that provide reimbursement for immunizations. Those with persistently low adherence should face reimbursement penalties.Medical practices or clinics with the highest rates of adherence to the federal immunization schedule should receive additional compensation from Medicaid, Vaccines for Children and other government programs that provide reimbursement for immunizations. Those with persistently low adherence should face reimbursement penalties.
It was good that New York passed a law this year prohibiting religious exemptions for vaccination of children entering school. However, there will be another outbreak in the near future unless we addresses the trend of vaccine hesitancy.It was good that New York passed a law this year prohibiting religious exemptions for vaccination of children entering school. However, there will be another outbreak in the near future unless we addresses the trend of vaccine hesitancy.
Jennifer Lighter is a pediatric infectious diseases physician and epidemiologist at Hassenfeld Children’s Hospital at NYU Langone. She helped lead its response to New York’s 2018-19 measles outbreak.Jennifer Lighter is a pediatric infectious diseases physician and epidemiologist at Hassenfeld Children’s Hospital at NYU Langone. She helped lead its response to New York’s 2018-19 measles outbreak.
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