Say it ain’t so, Mickey! A holiday measles outbreak makes the happiest place in the world sad

Last week, the self-proclaimed “happiest place on earth” wasn’t so happy.

One of the disadvantages of posting once a week is that, unless I muscle in on someone else’s day I can’t respond rapidly to stories that appear early. Of course the flip side of that is that if a story appears over the weekend it’s all mine, and, besides, I have my not-so-super-secret other blog to respond to issues that occur earlier in the week. Another advantage is that, if I do decide to write about something from earlier in the week, I have the advantage of time to think.

You’ve probably figured out that what I’m referring to is the latest measles outbreak. Not surprisingly, it happened in the Los Angeles area. Surprisingly (or perhaps not so much), it happened at Disneyland. I say “not surprisingly” because it’s been well-publicized over the last few years that there are pockets of low vaccine uptake and high personal belief exemptions in California, complete with measles and pertussis outbreaks. This is thanks to pockets of affluent, entitled parents full of the Dunning-Kruger effect who think that they can learn as much about vaccines and autism via Google University as pediatricians and researchers who have devoted their entire professional careers to studying them. Of course, these parents are also facilitated by pediatricians who cater to their fears, the most famous of whom is Dr. Bob Sears, whose The Vaccine Book is a very popular, reasonable-sounding (to parents not aware of the antivaccine tropes within) bit of antivax lite, but there is also our old buddy Dr. Jay Gordon and a host of others.

So what happened at Disneyland? On January 7, the California Department of Public Health confirmed seven measles cases:

California Department of Public Health (CDPH) has been notified of seven confirmed cases of measles in patients from five different locations within California it was reported today by Dr. Ron Chapman, CDPH director and state health officer. Two Utah resident cases have also been confirmed and three additional California residents are also suspected to have measles and are under investigation. All confirmed and suspect cases reported visiting Disneyland or Disney California Adventure Park in Orange County, California sometime between December 15 and December 20, 2014.

Based on information from current cases, it is likely that a person infectious with measles was at one of the theme parks on these dates. People can be infectious with measles for nine days. Measles typically begins with fever, cough, runny nose and red eyes and within a few days a red rash appears, usually first on the face and then spreads downward to the rest of the body. Measles is a highly infectious, airborne disease.

By week’s end, health officials were reporting a dozen cases and expecting more to appear. Of the total cases thus far, six of the original seven cases were in unvaccinated children. Late Thursday the health department reported:

Orange County health officials confirmed late Thursday that a total of five more people contracted the disease, bringing the countywide total to six cases.

Of those diagnosed, three were unvaccinated children — who were all old enough to be vaccinated — that contracted measles between Dec. 15 and Dec. 20 at the amusement park, said Orange County Health Care Agency spokeswoman Nicole Stanfield.

Three others are adults; one was unvaccinated, one was partly vaccinated, and one was fully vaccinated. None of the adults were hospitalized, Stanfield said.

On Wednesday, California’s Department of Health reported nine confirmed cases of measles, of which seven cases are in California and two in Utah.

Other sources were reporting that the total had reached 17. It wouldn’t surprise me if, by the time this post goes live, the figures I’m reporting here are outdated and the number of cases goes even higher still. Among these are at least two infants too young to be vaccinated. From what I’ve been able to ascertain, most of the victims were not vaccinated. This is in contrast to other outbreaks, where the majority of those getting the measles were actually vaccinated. Antivaccinationists point to this, crying “Most of the measles cases were vaccinated!” This is a common antivaccine trope that sounds reasonable on the surface. Unfortunately, the measles vaccine is not 100% effective. No vaccine is. It is, however, highly effective, and, if one actually corrects for the percentage of the population that is vaccinated, one invariably finds in such outbreaks that the risk of acquiring measles is much higher in the unvaccinated. In the Disneyland outbreak, antivaccine activists can’t even make that claim, as it appears that the majority of those who caught the measles were either unvaccinated or incompletely vaccinated.

I had never really thought of it before, but a theme park is an excellent incubator for an outbreak of a disease as highly infectious as the measles, particularly a theme park like Disneyland. While many theme parks tend to attract mainly from their region, theme parks like Disneyland, Disneyworld, Universal Studios Orlando, and the like, attract visitors not just from their region but from all over the world. That includes countries where there are ongoing measles outbreaks and high percentages of unvaccinated children. Add to that a location in a state where there are populations of children with low MMR uptake who visit Disneyland too, and the recipe for an outbreak is there. Over the Christmas holidays, it finally happened.

Antivaccine pediatricians run

I’ve mentioned antivaccine and antivaccine-sympathetic physicians in southern California before. It’s not surprising that the most prominent are running like the wind from news of the Disneyland outbreaks.

For example, given that he’s the foremost seemingly “reasonable” promoter of antivaccine pseudoscience, it’s not surprising that Dr. Bob Sears is once again feeling the heat, as well he should. You might recall that, in response to previous outbreaks in southern California, Dr. Bob let loose with a rather despicable couple of posts to his Facebook page, in which he expressed vexation with parents who, rightly concerned about the measles outbreak, were apparently deluging his office with calls of concern and asking if they should get their children vaccinated. His first response to them was basically a highly unprofessional rant entitled “Measles Epidemic…Not!” and boiled down to, in essence, “get the vaccine if you’re worried, but there’s no real reason to worry,” a complete abdication of his professional responsibility as a pediatrician. He also downplayed the significance of the measles outbreak in a fashion completely unbecoming a pediatrician (or physician of any kind). Basically, Dr. Bob’s message was: Don’t worry, be happy, and, if you’re worrying and not happy, get the vaccine. Just don’t bother me about it anymore. Oh, and you nasty pro-science vaccine supporters (whom he described as “mandatory vaccine militants”) out there are big meanies for pointing out that I’m irresponsible and antivaccine.

So great was the heat Sears felt, even from his own “vaccine-averse patients,” that he felt obligated to post a follow-up. And so he did in a Facebook post entitled “Orange County Measles Epidemic . . . Not (yet, anyway)!” This time, the message, also highly unprofessional, boiled down to, “Don’t worry, be happy, and if you’re worrying and not happy get the vaccine. Just don’t bother me about it anymore.” Oh, and “I’m giving informed consent.” The problem, as we’ve documented many times here, is that Dr. Bob and his fellow antivaccine activists don’t give informed consent. They provide “misinformed consent” that vastly inflates the risks of vaccines, attributes nonexistent risks to them (such as autism; more on that later), and minimizes the benefits of vaccines.

This time around, Dr. Bob appears to have learned a lesson from his previous crybaby outbursts. He’s managed to control his petulance a little better. On Thursday, he wrote a post entitled “Measles Makes a Stop at Disneyland“. His tone is much more measured, but underneath lies the same old attitude, in particular his downplaying the seriousness of the measles. Indeed, after acknowledging that the measles can be “miserable,” well, here’s how Dr. Bob put it:

The bad news – although I make light of people’s tendency to panic unnecessarily, measles is no laughing matter for those who are exposed to one of these nine cases. Although most cases pass harmlessly in the long run, it is a miserable week. Severe complications are very rare, thankfully. But moderate complications, like pneumonia, can occur. It can also be more severe for infants and for pregnant moms and for immunocompromised people. Our hearts go out to any of these high-risk people who are exposed. But most complications are manageable. So, it is a worry for exposed people, I know. But for the public at large, we should just go about life as usual. For anyone exposed to those nine, you are being managed by your doctor and the health department.

As with all previous measles outbreaks, there’s no reason to panic. Here is some info to know:

If vaccinated with one dose of MMR, you have a 95% chance of being immune. If two doses of MMR, 99% chance. But this isn’t perfect. As you will read in the link, one of the cases was fully vaccinated.

Make light of people’s tendency to panic? A more accurate way of saying it would be that Dr. Bob heaped scorn on people’s concerns, not just once but twice. Still, at least he acknowledges the potential complications, but even then he can’t resist downplaying their seriousness. Pneumonia a “moderate complication”? No, it’s a serious complication that very frequently requires hospitalization. I suppose it’s a minor victory, though, that he acknowledges that the MMR is highly effective, particularly when multiple doses have been received, but one still can’t help but note that Dr. Bob had to harp on the fact based on information available at the time that one of the cases was fully vaccinated.

Meanwhile, I had an exchange with our old buddy Dr. Jay Gordon on Twitter, based on this Tweet:

Of course, the CDC recommends that children receive their first dose of the MMR vaccine between age 12 and 18 months. So what’s this with Dr. Jay’s obfuscating? I and others asked him on Twitter:

Dr. Jay responded to me and others:

To which I responded:

Dr. Jay responded:

Which wasn’t an answer. So I and others pestered him. Finally, he said:

And:

So, as I’ve observed before, Dr. Jay won’t give the MMR (or, it would seem, any vaccine) unless the parent badgers him to do it. Basically, like Dr. Bob, he washes his hands of the decision (and therefore responsibility) to vaccinate, justifying it by saying he’s just letting the parents choose. The problem is that he’s “letting them choose” based on misinformed consent, in which his copious statements expressing “concern” about vaccines, invoking the “toxins” gambit, and likening vaccine manufacturers to tobacco companies, as he states unequivocally that vaccine cause autism.

Not coincidentally, after Dr. Jay was cornered on Twitter, he had a couple of new posts on his blog to justify his “concern” for vaccinating children under three. First, he referenced the conspiracy-laden “#CDCWhistleblower” manufactured scandal and referred to the original paper by DeStefano et al. to justify his concern about vaccinating children under three. As I explained in three lengthy posts, neither that study, Brian Hooker’s now-retracted paper, nor William Thompson’s conscience tortured over fairy dust, show that the MMR vaccine causes autism when given before age 3. Dr. Jay clearly misunderstands the science.

Dr. Jay’s second post is entitled “The MMR is not controversial because of Wakefield“, a title that almost destroyed my keyboard, as I was foolishly taking a sip of my Sunday morning coffee when I first read it. Key gems:

The vaccine is best given later because it can cause large side effects in a small percentage of kids when given at 12-15 months. Parents’ testimony, the above CDC publication and much more supports this conclusion.

Dr. Jay provides no evidence to support this and no citations, but this is of a piece with what Dr. Jay contributed to the response to the earlier measles outbreaks in southern California. His letter to his patients basically echoed Dr. Bob, saying, “If you would like the MMR vaccine, feel free to get it.”

He then concludes:

When we coerce parents into vaccinating their children younger than they feel comfortable doing, we diminish their confidence in their doctors and compromise our ability to continue the dialogue about vaccines and all aspects of their children’s care. If one really cares about herd immunity–and I do–respecting parents’ decisions is crucial.

Of course, a huge part of “respecting parents’ decisions” is to give the parents accurate scientific and medical information, rather than antivaccine fear mongering. If parents’ pediatricians say or imply that vaccinating (or vaccinating before a certain age) is dangerous when it’s not, the parents will likely believe it, particularly if they are predisposed to believe bad things about vaccines. Dr. Jay, whether knowingly or unknowingly, presents a slanted case to his patients’ parents, thus making it highly unlikely that they will agree to the MMR before age 3. Of course, if Dr. Jay doesn’t even offer it before age 3 and has to be pummeled by pro-vaccine parents into giving the vaccine earlier, then very few of his patients will get it before age 3. Parents who have to badger their child’s pediatrician to vaccinate will pretty quickly realize that this is not the pediatrician for them and find another who vaccinates according to the CDC schedule. Dr. Jay’s patients are thus self-selected to be vaccine-averse, and he caters to that. After all, he is well known as Evan’s pediatrician (Jenny McCarthy’s son) and has even written the foreword of one of her books.

Unfortunately, the problem of pediatricians who are either antivaccine, antivaccine-sympathetic, or have come to cater to vaccine-averse parents is a huge problem in California. There are, not surprisingly, pediatricians who aren’t as famous as Dr. Bob Sears or Dr. Jay Gordon contributing to this problem. They are misleading parents and catering to the scientifically-unfounded fears of others.

Meanwhile, VaxTruth.org posted a highly misinformation- and fallacy-laden response to the Disneyland measles outbreak, complete with one of the most intellectually-dishonest antivaccine tropes out there, the infamous “vaccines didn’t save us” trope. It was coupled, of course, with a “What, me worry?” trope in which the writer did everything she could to downplay the seriousness of the measles. It might be worth a separate post.

No, vaccines do not cause autism

Ironically, just before news of the Disneyland measles outbreak hit the press, a mere couple of days into 2015 there was published a study that reinforced the already copious scientific evidence that neither the MMR nor thimerosal preservative in childhood vaccines is associated with autism. The study was entitled “Early exposure to the combined measles–mumps–rubella vaccine and thimerosal-containing vaccines and risk of autism spectrum disorder” and comes to us courtesy of Nagoya University, the Yokohama Psycho-Developmental Clinic, Fukushima University, and Juntendo University.

I realize that I’ve already given away the punchline, namely that this is yet another in a long line of studies that failed to find a link between vaccines (in particular the MMR) and autism or between thimerosal-containing vaccines and autism, but the journey to refuting antivaccine quackery with pseudoscience is more than half the pleasure. So let’s take a look.

The authors started out discussing the studies that didn’t find a link between either MMR vaccination and autism, or between thimerosal-containing vaccines and autism. So why did they bother to do a new study? Their rationale is actually kind of interesting:

However, most studies have not considered vaccinations’ timing and the subject’s racial heterogeneity even though genetic factors are known to be strongly involved in ASD onset. As an investigation that specified the race of the study participants, we conducted a case–control study from the Japanese population [19]. Japanese people were proven to be highly genetically homogenous according to the genotyping results of 140,387 single nucleotide polymorphisms [20]. In our previous study, there was not any convincing evidence that MMR vaccination was associated with an increased risk of ASD in Japanese people. However, the effects due to the differences in vaccinations timing and the amount of exposure to thimerosal were not accounted for in this study.

OK, fair enough. The Japanese are a pretty genetically homogeneous people compared to most other areas where the question of whether vaccines cause autism has been studied, but, given the multiple resoundingly negative studies done before, it’s highly unlikely that doing it again in the Japanese would provide a different result, and it didn’t. Don’t get me wrong. This is a good study and is an important addition to the existing body of evidence supporting vaccine safety. It’s just irksome how the antivaccine movement forces scientists to reinvent the wheel again and again.

What about the study itself? It’s a case-control study, which means looking at vaccine history in autism cases versus controls after controlling for known confounders and determining if there are differences in MMR vaccination or thimerosal exposure. Basically, vaccination histories at 1, 3, 6, 12, 18, 24, and 36 months from birth were investigated in ASD cases (189 samples) and controls (224 samples) matching age and sex in each case. Crude odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Then dosages of MMR vaccine and thimerosal were examined and investigated using a conditional multiple-regression model in order to determine if there were is any relationship between autism and overall exposure. The population providing case data came from the Yokohama Psycho-Developmental Clinic (YPDC), a clinic that only accepts patients with suspected neurodevelopmental disorders. Eligible case subjects were evaluated by the YPDC between April 1997 and March 2011 and were (1) diagnosed with autism spectrum disorder and (2) had been born between April 1, 1986 and April 30, 1992.

There’s also a quirk in how the cases were chosen based on the unique situation in Japan with respect to the MMR vaccine:

MMR vaccination in Japan was conducted under specific circumstances and for only a short period of time. A combined MMR vaccination program commenced from April 1989, and only one vaccination using MMR was included in the immunization schedule. The monovalent mumps, measles, and rubella vaccines remained the optimal choice of vaccine for those who did not participate in the MMR program. However, soon after the immunization program had started, there were several cases of aseptic meningitis, which may have been caused by the mumps vaccine [31]. As a result, in April 1993, the Government ceased extensive inoculation with MMR. Therefore, children who were born from April 1984 to April 1992 could receive MMR vaccination. However, children who were born between April 1984 and March 1986 were able to receive it after the age of three. Therefore, they were excluded from the samples, because autism features always appear before the age of three. As a result, children who were born from April 1986 to April 1992 were included in the present study.

These days, Japan still vaccinates against measles, but, because it was the mumps component of the MMR vaccine used in Japan that caused problems over 20 years ago, the Japanese now require a combined measles-rubella (MR) vaccine instead, which is mandatory. The mumps component is voluntary but recommended. Of course, it’s hard not to note that autism rates continued to rise in Japan even after the discontinuation of the use of MMR-combined vaccine and substitution with two separate vaccines that, together, cover the same diseases. Same as it ever was. As far as science has been able to ascertain after much trying, vaccines don’t cause autism; so it should not be surprising that discontinuing a vaccine demonized as the cause of autism does not result in a decline in autism prevalence.

In any case, the control group consisted of age- and sex-matched subjects recruited as volunteers from general schools in the Kanto area, which is the same area where YPDC patients live. Students who had previously been diagnosed with developmental disorders or problems were excluded.

So what were the results? I already told you, but it’s worth quoting the study:

There were no significant differences in MMR vaccination and thimerosal dosage between cases and controls at any age. Furthermore, the ORs (95% CIs) of MMR vaccination and thimerosal dosage associated with ASD in the conditional multiple regression model were, respectively, 0.875 (0.345–2.222) and 1.205 (0.862–1.683) at age 18 months, 0.724 (0.421–1.243) and 1.343 (0.997–1.808) at 24 months, and 1.040 (0.648–1.668) and 0.844 (0.632–1.128) at 36 months. Thus, there were no significant differences.

The authors thus quite properly concluded that there was no convincing evidence that MMR vaccination or increasing thimerosal dose are associated with an increased risk of ASD onset. Once again, there was not a whiff of a whisper of a hint of elevated MMR or thimerosal exposure in the case group compared to controls. A key strength of this study is that parents of children receive a document referred to as the Maternal and Child Health (MCH) handbook, which is described by the authors as a “highly reliable data record of early development, health, and immunization, and the data are recorded by health professionals (e.g., public health nurses, obstetricians, and pediatricians).” This allowed the investigators to access detailed, accurate immunization records for cases and controls, and they excluded subjects in which entries regarding vaccines in the MCH handbook were missing or illegible. This allowed not only accurate assessment of the number of MMR vaccines each subject received, but also the total dose of thimerosal received by each subject.

So once again, a year starts out with researchers asking the questions:

• Is MMR vaccination associated with an increased risk of autism?
• Is thimerosal exposure in vaccines associated with an increased risk of autism?

Again, the answers to these questions are no and no. Vaccines do not cause autism. Again.

In fact, so common is this finding now that, contrary to the Disneyland measles outbreak, I didn’t see a single news story about this study. That’s rather unfortunate, because I believe that it helps to publicize such studies as yet another example of the depth and breadth of the evidence that has failed to find a link between vaccines and autism and to counter the misinformation spread by the antivaccine movement and, even worse, by pediatricians who should know better.

It’s not at all surprising that the first measles outbreak of 2015 (or the last measles outbreak of 2014, depending upon how you want to look at it) occurred in southern California. It’s one of the best places in the country for it. Unfortunately, the same sort of attitudes have infested my state, as evidenced by recent measles and pertussis outbreaks here. The attitudes are the same, and the results are the same. We’re just fortunate enough not to have an international destination that packs children of all ages from all over the world together as a place to facilitate outbreaks.