Tuesday, May 4, 2021

We need childhood vaccination to make COVID-19 as rare as chicken pox or the measles

When I was 16 years old, I contracted the chicken pox from my younger sister, who had inadvertently carried the varicella-zoster virus home from a classmate at her middle school. Her symptoms lasted for a few days and were relatively mild, but I was out of school for two full weeks and was thoroughly miserable for most of that time. I developed blisters in my mouth and throat that made it painful to chew and swallow, and after the full-body rash finally cleared, I was left with several permanent keloids (scars) from scratching, one of which needed to be biopsied several years later to make sure that it wasn't skin cancer. Just three years later, an effective varicella vaccine was introduced in the United States and incorporated into the routine childhood immunization schedule. The Centers for Disease Control and Prevention (CDC) estimates that varicella vaccination prevents 9,000 hospitalizations and 100 deaths in the U.S. each year. Even though my infection was not remotely life-threatening, I absolutely would have gotten the vaccine, had it been available, to avoid the illness that I endured.

During my family medicine residency in Lancaster, PA, I gave a presentation on the rubella vaccine, which is the "R" in the MMR vaccine that nearly all U.S. children have received since the 1970s. I say "nearly all" because the Amish communities that my residency program served had historically declined most vaccinations. Although rubella infection can be asymptomatic and usually causes a few days of mild flu-like symptoms and rash in children and adults, it can cause birth defects if a woman contracts it during pregnancy, particularly during the first trimester. From February through May 1991, a widespread rubella outbreak swept through Lancaster and surrounding counties. The CDC identified 94 Amish women who reported a rubella-like illness or had serologic evidence of acute rubella during their pregnancies. Seven women miscarried; of the 87 live births, 7 had possible congenital rubella syndrome (CRS) and 11 had confirmed CRS:

Clinical abnormalities for the 11 infants with CRS included congenital heart disease (nine), deafness (six), purpura (four), long bone radiolucencies (four), cataracts (three), thrombocytopenia (three), hepatosplenomegaly (two), intracranial calcifications (two), encephalitis (one), microcephaly (one), failure to thrive (one), seizures (one), and disseminated intravascular coagulation (one).

Also in the early 1990s, the health department in nearby Philadelphia battled an outbreak of the measles fueled by a fundamentalist religious group (Faith Tabernacle Congregation) that not only did not believe in providing MMR vaccinations, but in any intervention for sick children other than prayers. Although the overall death rate from measles is no greater than 1 in 1000, tragically, four out of 150 infected children in the congregation died, due to a combination of the infection and delayed medical care. Measles outbreaks don't only incur physical and emotional costs; they cause massive public health, medical care, and productivity costs too. As reported in Pediatrics, a 2019 measles outbreak in Clark County, WA that involved only 72 confirmed cases ended up costing $3.4 million, or $47,479 per case, mostly from the public health response, contact tracing, and the need to quarantine more than 800 unvaccinated or inadequately vaccinated exposed persons.

The U.S. Food and Drug Administration is apparently poised to authorize administering the Pfizer COVID-19 vaccine to 12 to 15 year-olds as early as next week, not a moment too soon, as the success of the adult vaccination campaign has dramatically protected older persons to the extent that nearly a quarter of new infections are now occurring in children. Children and young adults are significantly less vulnerable than middle-aged or older adults; the American Academy of Pediatrics estimates that children make up only 1-3% of hospitalizations, and just over 15,000 children have been hospitalized since the start of the pandemic out of 3.8 million infected. It's worth pointing out, though, that these figures are similar to those from measles and chicken pox in the years before routine MMR and varicella vaccination. Drs. Perri Klass and Adam Ratner recently asserted that the widespread acceptance of MMR vaccination in the U.S. is an apt historical comparison to the "ethical obligation [and] practical necessity" of vaccinating children against today's viral pandemic:

Vaccinating children is likely to have benefits both direct (protecting children against rare severe pediatric cases of Covid-19 and postinfectious conditions such as multisystem inflammatory syndrome in children [MIS-C]) and indirect (protecting others by reducing spread). Those “indirect” benefits also reduce the family toll of parental illness, failing economies, and chronic stress. ... So we need to think creatively and empathically about what motivates parents to accept vaccination for their offspring. How do the conversation and the stakes change when children are not themselves at highest risk?

Former CDC Director Tom Frieden's Resolve to Save Lives Initiative has posted a compelling series of case studies on its website on "Epidemics That Didn't Happen," including several countries that, unlike the U.S. and most Western European nations, were able to successfully blunt the impact of COVID-19. A common thread running through many of the other case studies was early recognition of the outbreak and rapid deployment of an effective vaccine to squash the infectious threat before it spread out of control. Obviously, this strategy wasn't feasible against a novel coronavirus in 2019 and most of 2020, but near-universal vaccination can work now to end the pandemic and stop future local outbreaks when and where they occur.