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)

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