Archives for May 2019

Shetal Shah, MD, FAAP

Dr. Shetal Shah, MD, FAAP is a neonatologist at Maria Fareri Children’s Hospital.  He is NYS AAP Chapter 2 Vice President and Chair of the Legislative Committee.  This op-ed was published on northjersey.com on May 9, 2019.

Forty years ago, the United States eradicated endemic polio.  It was a cooperative, national effort to eliminate a major public health threat, made possible by a lifesaving vaccine, an army of healthcare professionals and by parents who chose to vaccinate their children — many waiting in line for hours.  Vaccines are considered one of the world’s greatest health achievements and are the main reason current parents of young children don’t remember polio, rubella, diphtheria and until recently, measles.  Prior to the creation of measles vaccine over a half-century ago, approximately 3-4 million US cases occurred annually, resulting in thousands of hospitalizations, cases of lifelong disability and hundreds of childhood deaths.

New York is again facing outbreaks of measles.  Almost 700 cases have been reported nationally the largest since the disease was considered domestically eradicated — largely from clusters of unvaccinated children in Brooklyn and Rockland County.  The number of infected keeps rising.  In a single week in April, 78 new cases were reported.

Washington State is also facing an outbreak and cases of measles span 22 states.  Since 2001, over 100 measles outbreaks have occurred, including the 2014 episode centered on Disneyland.

Pediatricians foresaw the return of vaccine-preventable diseases because each week, we spend hours discussing the importance of vaccination to increasingly skeptical parents who, fueled by misinformation as well as unsubstantiated claims nurtured on the internet, cite greater concerns about the vaccines than the diseases they prevent.

When vaccination rates decrease, the return of measles, (or pertussis, or mumps) is inevitable.  Parental refusal of vaccines is now so prevalent the World Health Organization declared it a “Top Threat to Global Health” this year, alongside HIV/AIDS and poor access to medical care.  While measles has captured the public’s attention, there have been 426 cases of mumps this year, approximately 300 in March alone.  Pertussis outbreaks occur so often they are now considered medically “routine.”

Worse than the suffering these diseases can cause (5 children have required intensive care from measles complications) is having the public health tools to prevent these illness and not using them.  This is why the New York State Legislature should pass bills A.02371/S.02994 and eliminate all non-medical exemptions to vaccination for school attendance.

New York State allows parents to obtain religious exemptions from vaccination and more parents are getting them. Though most major religions support immunization – rates of religious exemptions in the state are now high enough to weaken population immunity levels (herd immunity) that almost 300 schools in the state are at risk. Moreover, what is often overlooked is the general population vulnerability of these diseases in immune compromise individuals such as those suffering with cancer, and others with impaired immune defense mechanisms such as AIDS as well as those with true contraindications who cannot be immunized.

Though New York, unlike 17 other states, does not allow for a philosophical exemption (a wish to not be immunized simply because one is against vaccination), it is clear religious exemptions are often truly philosophical ones dressed in religious doctrine.  Having reviewed applications for religious vaccination exemptions, it’s clear many parents are trying to opt out of vaccination by co-opting religious texts – sometimes from multiple religions which parents state they do not follow.

Since religious exemptions are granted by local school boards, some parents feel if they complain enough, or threaten to sue, schools will relent.  This process also makes school boards de facto courts of faith, dissecting which exemptions are rooted in religious conviction and which are not – a job school officials do not want and are often unqualified for.

In the wake of this year’s measles cases, Washington State is attempting to learn from the outbreak.  A bill to restrict exemptions to vaccination passed the state’s Senate.  The question is, can New York learn the same lesson?

This measure, sponsored by Legislators Dinowitz and Hoylman enjoys widespread support from physicians, public health groups, healthcare workers and parents of school-age children.  If passed, the bill would put New York on equal footing with West Virginia and Mississippi – two states which have not experienced widespread outbreaks and with California – which despite having measles next door in Oregon has to date been spared a major repeat of its 2014 experience.

Regrettably, a small, well-organized group of opponents have harassed legislators and pediatricians, both in person and on social media. Their tactics not only are reprehensible and in some cases dangerous.  These groups have overtaken town halls and disrupted public events.  Protestors surrounded the car of New York State Senator Kevin Thomas, who supports the bill — and refused to leave, requiring the Senator to call the police.  Assemblyman Dinowitz has been told by anti-vaccine activists, according to a report, that they hope his “grandchildren get autism.”

Pediatricians support this bill because allowing only medical exemptions is a proven way to increase immunization rates and protect all children from vaccine-preventable diseases.  Since all kids who get immunized don’t generate an immune response sufficient to protect themselves, ALL parents should support this bill as a way to protect ALL our state’s children.  It eliminates school boards from becoming arbiters of vaccination exemptions – which leads to different standards in each district – and places authority to grant exemptions in the hands of physicians.

These epidemics should motivate legislators to understand the importance of strengthening our public health infrastructure.  If they fail to recognize the medical and epidemiological facts behind immunization and the policies which keep rates of vaccination high, then another outbreak is certain.

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.)

NYS Legislators: Please Support Bill that Will Allow Only  Medical Exemptions to Vaccination, S.02994 and A.02371

Vaccination has been the most important and impactful scientific achievement of modern times.  Yet because of misinformation fueled by social media, there remain pockets of unvaccinated children whose parents hide behind a cloak of religious exemption as protection from unfounded fears.  There are, in fact, no major religions that prohibit vaccination.  Sadly, these parents have put not only their own children at risk but the communities in which their children live, play and attend school.  The current measles outbreak is evidence of what happens when children go unvaccinated.

Measles is a highly contagious virus.  The current outbreak has now infected 695 people in 22 states.  Measles can lead to pneumonia, a brain infection called encephalitis, deafness, a prolonged immunocompromised state, and a rare complication called SSPE or subacute sclerosing panencephalitis that can occur years after infection and is fatal.  In 1962, the year before the measles vaccine was available, 3-4 million people were diagnosed with measles, 48,000 were admitted to hospitals and 500 people died.  By the year 2000, measles had been eliminated from the United States because of the vaccine.  However because of growing numbers of parents choosing not to vaccinate their children, we have begun to see increased outbreaks in recent years, with this year’s being the largest since the disease was eliminated nearly twenty years ago.

Particularly susceptible to serious illness in these outbreaks are infants under one year old who have not yet been vaccinated, and immunocompromised children and adults who are receiving or have recently received chemotherapy and other immunosuppressives to treat cancer and chronic diseases.

Vaccines save lives.  The Hib vaccine has virtually eliminated disease caused by Haemophilus Influenzae B which before its introduction in the late 1990’s affected 25,000 children yearly, causing meningitis, paralysis, blindness, pneumonia and a severe life-threatening respiratory illness called epiglottis.  Since the introduction of the Prevnar vaccine in 2000 there has been a dramatic decline in rates of meningitis, blood infections and other invasive life threatening disease caused by pneumococcal bacteria.

Vaccines are scientifically proven to be safe and effective and have saved tens of millions of lives over the past several decades.  Parents today are lucky to live in a time when we do not have to live in fear of our children contracting serious and deadly diseases.  However the current outbreak has demonstrated that if parents fall prey to misinformation and fail to properly vaccinate their children they put their own children at risk as well as the most vulnerable among us.

The American Academy of Pediatrics representing 67,000 pediatricians across the country is advocating for an end to state laws that allow people to refuse vaccination of their children on religious or philosophical grounds.  I urge NYS legislators in the Senate and Assembly to pass S.02994 and A.02371.  This bill will allow only medical exemptions to vaccination.  I implore our legislators to believe science and to protect children and at risk residents in our state.

I implore parents and community members who understand the importance of vaccination to ask their NYS legislators to support the bill.   It is always tragic when children die or develop devastating long term consequences from disease.  However the most tragic of those are cases that are entirely preventable.  Let us not fail our children.  Let us not fail those among us who are immunocompromised, who are too young to get vaccinated or who are undergoing treatment that prevents them from getting vaccinated.  These individuals, parents and children live in fear during outbreaks such as we are experiencing now.  Let us not deny them the protection they need and are entitled to.

Steven J. Goldstein, MD, FAAP

(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens. He is president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health. This blog post was originally published in AAP Voices on April 30, 2019)

The outbreak of measles in New York City brings back vivid memories more than half a century old.  I was 5 years old and was very ill, with a terrible cough, dry lips, crusted eyes, extensive rash, and high fever.  My pediatrician visited while I was sick, and he was a welcome sight.  I had terrible light sensitivity and spent most of the time in a semi-dark room.

Only in medical school did I learn that I had exhibited classic measles symptoms: cough, coryza, and conjunctivitis with photophobia, fever and rash.  The virus infected more than three-quarters of a million people and killed hundreds in the United States that year, a decade before the measles vaccine would become available.  Fortunately, I escaped serious complications of the disease.

I think the experience helped influence me to become a pediatrician.  Not a reason to contract measles, though.

As I age, I am less patient waiting for positive change as I realize the work of individual pediatricians to make the world a better place is time-limited.  This is one reason I am incensed by the return of measles to the neighborhoods where I practice.  As of April 29, there have been 423 confirmed cases of Measles in Brooklyn and Queens.  The vast majority of patients, roughly 84 percent, are infants, children and teens.

Vulnerable communities targeted with vaccine misinformation

My Brooklyn office serves a largely Chasidic clientele, with a melting pot of families from other backgrounds.  My Queens office patients are reflective of one of the most diverse communities in the US.  We first noticed a troubling trend in the Brooklyn office.  Starting in late 2017, there was a significant drop-off in babies and children coming in for well visits and immunizations.

An anti-vaccine group calling themselves PEACH (Parents Educating and Advocating for Children’s Health) in the ultra-Orthodox community of Lakewood, New Jersey sent out an illustrated, 40-page booklet filled with false information about vaccines.  Targeting isolated and fundamentalist communities, where the science of immunizations is not well known and accepted, is a known tactic of the anti-vaccine activists.

A helpful publication from the Hudson Valley Health Coalition that countered the misinformation with facts was distributed by the New York City Department of Health and supported by the CDC.  Our immunization rates dropped nevertheless, and it was the rare visit that did not engender a long discussion about vaccine risk, efficacy, and timing.  Long discredited claims of a possible MMR immunization and autism link were revived, and questions about the need for vaccines against “eliminated diseases” arose.

The ultra-Orthodox community in Brooklyn has seen measles before.  In 2013, an unimmunized child returned from London incubating measles, resulting in 58 cases in New York City.  Forty-five of the affected patients were eligible to receive vaccine but had not.

The toll of outbreaks on the health care system & practices

The costs to society of outbreaks such as these, which divert funds from worthy initiatives, are not trivial.  The costs to the Department of Health in the 2013 outbreak were calculated to be about $400,000.  According to federal estimates, the direct and indirect costs of each case of measles can run as high as $142,000.

As I write this, the ongoing spread of measles from Brooklyn causes worry about the possible spread to other municipalities, especially with recent holidays when many families traveled long distances.  The question of how to protect very young children remains, other than advising families not to travel and isolating them as much as possible.  But what about someone inadvertently bringing measles into our office, hospital, ED, or clinic?  This should be of major concern to all of us, because it has implications for structuring our schedules and patient encounters.

Facilities must close for two hours after measles is diagnosed because of the continued contagion of virus in the air.  Suspected cases also disrupt practices. Last week in Queens, we saw a 2 1/2 year old child with history of one MMR vaccine who attended a childcare nursery in Brooklyn, near to an affected community.  He’d had 4 or 5 days of fever and then developed a rash, so we had to consider measles.

We learned two days later from his lab work that the polymerase chain reaction was negative.  It was not measles.  Still, the burden on staff to check the immunization status of each child in the office those days and if needed, to contact their families, was huge.  Because of the time frame and age, some children would need immune globulin prophylaxis or vaccine, and might need to be quarantined for up to 28 days.  Newborns might have been exposed. I lost sleep.

The return of measles has the potential to profoundly influence the way we, in the affected communities, practice pediatrics.  We were extremely unhappy about the possibility that a child in our office might have exposed others.  Pediatricians will need to consider measles immunity, the possibility of measles in the pre-rash stage, and the incubation period when scheduling patients, and attempt to isolate susceptible patients from others if the epidemic spreads.

Wild measles: trampling families’ freedom from disease

Because of the spread of measles to the Detroit community, with 50 cases documented at last count, my own daughter has decided to forego daycare for her new baby and will hire a nanny to minimize the infant’s chance of getting the disease.

One argument the anti-vaccine community makes is that by insisting on immunization, we are infringing on individual freedoms.  What about the rest of the world that stands to suffer, with risk of death or disability, because of measles spread by vaccine refusers?  Wild measles is the gift that keeps on giving, with subacute sclerosingpanencephalitis (SSPE), a fatal, late onset measles complication, a real possibility.  Some of us think, given the number of cases so far, that there will be a major spike in SSPE in a few years.  Measles is not a benign disease.

This issue — the inability of young children and others susceptible to infectious diseases — is a cogent argument for the passage of bills eliminating all but medical exemptions for vaccines.  New York is considering this issue and other states should as well, joining California, West Virginia and Mississippi.  The most recent estimates suggesting that for every 1000 cases of measles, one or two patients die, it is clearly a public health issue.

In the meantime, as pediatricians fighting on the front line of outbreaks, we are faced with a new normal as we continue to factor measles into our decision-making when booking and seeing patients to protect our most vulnerable patients.  Most importantly, we continue our efforts to educate families about the dangers of measles–and how the decision not to vaccinate affects everyone around them.