Reality is one honey badger. It don’t care. About you, about your thoughts, about your needs, about your beliefs. You can reject reality and substitute your own, but reality will roll on, eventually crushing you even as you refuse to dodge it. The best you can hope for is to play by reality’s rules and use them to your benefit. Combined with a little luck (nothing quite as beneficial as being a white, middle class male in the US) you might have a reasonably healthy health.

The most reliable way to understand reality is science and the scientific method. Used wisely you may have a shot at minimizing morbidity and mortality. Deny or ignore it and reality don’t care. Reality will get us all.

We all have our biases, recognized and unrecognized. I often see the world in terms of infectious diseases. When I read Team of Rivals: The Political Genius of Abraham Lincoln I enjoyed the politics and personalities but I was struck by how people constantly died young of infectious diseases. We don’t see mortality in the young anymore for a variety of reasons: better nutrition, an understanding of the pathogenesis of disease, clean water, flush toilets and vaccines.

Vaccines have helped pushed many diseases into obscurity that were once common. It has been 30 years since I graduated medical school and I have never seen a case of measles or diphtheria. I have seen one case mumps, one of polio, one of tetanus and one of German measles. And lots and lots of pertussis.

Most people have not lived in a time of plagues or remember their effects. Most people do not read history or look at the morbidity and mortality of vaccine-preventable illnesses in the third world. But the reality is that vaccine-preventable illness are still there and the barriers to prevent their return are surprisingly fragile. It doesn’t take much thinning of herd immunity to allow vaccine-preventable illnesses to come storming back. We are always skating close to the edge of infectious outbreaks and not aware of the danger. But reality don’t care if we think vaccines do not work or cause autism or that we give too many too soon. Stop vaccinations and it is not if but when we will see the infections return. We think we are safe from vaccine-preventable illness. We are not.

There have been many natural experiments that demonstrate how little it takes for infections to gain a toehold once they find a susceptible population. The current brouhaha ha ha is over the megachurch in Texas where it was de rigor to trust in God rather than vaccinations to prevent infections:

To get a vaccine would have been viewed by me and my friends and my peers as an act of fear — that you doubted God would keep you safe. . . . We simply didn’t do it

So far 21 people have developed measles, 16 of them unvaccinated (I just finished a zombie trilogy and I tend to think of the word ‘unvaccinated’ like the word ‘undead’).  Measles has not escaped into the wild. Yet. But that is not the first nor is it likely to be the last outbreak of a vaccine-preventable illness.

When I first became active in SBM I was surprised as I looked back on my education on how little emphasis was placed on vaccines. In part it is because I am an adult ID doc (who I treat, not necessarily how I behave), in part I suspect that the benefits of vaccines, like fresh water and sterile technique, were a given.

The first large outbreaks of vaccine-preventable illness in previously-vaccinated populations occurred after the collapse of the USSR. Russia made most of the vaccine and for economic and other reasons the diphtheria and other vaccine rates plummeted in the old Soviet Union as supplies fell. As a result diphtheria went ballistic, from 200 cases a year to widespread disease in only 4 years:

The diphtheria epidemic began in 1990 in the Russian Federation, spread to Ukraine in 1991, and spread to 12 of the 13 remaining NIS during 1993–1994. In 1994–1995, the peak of the epidemic,>98,000 cases and 3400 deaths were reported in the NIS.

The disease was slowly controlled in part by re-instituting the vaccine program.

I remember thinking at the time what a tragedy it was that so many children had to suffer or die from such an easily-preventable illness, but that would never happen in Oregon or the industrialized nations.

But outbreaks keep happening whenever the vaccination rates decline. Why vaccination rates fall varies from county to country and from vaccine to vaccine. Some rational, some political, some kind of wackaloon. What ever the reason, reality don’t care why the population is susceptible and infections move in.

In 1993 the MMR vaccine was withdrawn in Japan due to high rates of aseptic meningitis from the mumps component. This was followed in 1994 by removal of the vaccine requirements to attend school. The result? A marked increase vaccine-preventable illness. 11,991 cases of rubella in the first six months of 2013 with 10 cases of congenital rubella. 76% of cases were in the unvaccinated.  For comparison:

2004–2012, 79 cases of rubella and six cases of CRS were reported in the United States; all of the cases were import-associated or from unknown sources.

Part of the reason the epidemic spread is that the Japanese only vaccinated females, so males have been a vector to allow the spread of disease. Not trying for herd immunity, they lost the ability to control the spread of infection. The only case of rubella I have seen was in 1999 when I visited a friend who lived in Tokyo who became ill with rubella the day I landed.

In 2007 to 2008 the Japanese had 27,000 cases of measles and they are trying to play catch-up with the vaccine. In 2012 the US had 222 cases of measles, 90% of which were imported and often occurred, like Texas, in communities with low or nonexistent vaccination rates.

Similar problems are occurring in Europe. There have been thousands of cases of measles, mumps and rubella that followed the decline in vaccination rates, with at least 78% of the measles cases in the unvaccinated.

Poland, Chile, Argentina, and Brazil, following the Japanese example of avoiding herd immunity, targeted only females for rubella vaccination and outbreaks continue in the male population, jumping to females with resultant cases of congenital rubella.

Nigeria, for complex reasons, including the belief that vaccines were being used to sterilize children, boycotted the polio vaccine. Reality don’t care why there was no immunity to polio and polio came back.

In the US most outbreaks of vaccine-preventable illness have been focused in communities, like the congregation in Texas, where vaccine-induced immunity has declined. The main exception is pertussis where the current acellular vaccine is not as effective as the older vaccine, although it has fewer complications.

Do you see a consistent pattern? Vaccinations are protective and when individuals are not vaccinated their risk for vaccine-preventable illness increases. When enough individuals are no longer immune, communities are have outbreaks. If you are not immune, for whatever reason, reality don’t care. If exposed you will likely get infected and pass it on.

I tend to be a booster of all things Oregon. It is almost the perfect place to live. Almost. Oregon does lead the US in unvaccinated children at 6.4%. Go Oregon. When you add to that the number of those who do not respond the the vaccine, I would bet the at-risk population is greater than 10%, although the unvaccinated tend to cluster in pockets i.e. schools, perhaps increasing the risk for disease amplification in the community. Diseases don’t care what granfalloon you are a member of. It may get a jumpstart in a group of the unvaccinated but it will not be contained there.

Infectious diseases, as I have mentioned in the past, is similar to birding, except that it is actually interesting. I have a life list, those infections I have seen or expect to see in my career. I had never expected to see a case of measles or diphtheria or rubella or mumps. This is probably about to change.

Every time I walk the rat warrens of Chicago O’Hare or similar hub I think “what an excellent place to spread measles, rubella, smallpox or the contagion that brings on the zombie apocalypse“. All the vaccine-preventable infections are a red-eye flight away from the US. It is small world with fragile defenses against infections, a thin red line of immunoglobulins.

The number of unvaccinated are creeping up in the US and in the formerly-great state of Oregon and with it the potential for more outbreaks. And it is not if. It is when. Reality don’t care.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at