Kent State epidemiologist Tara Smith talks about vaccines, recent preventable measles outbreaks and her 2017 journal article on vaccine rejection.
Welcome to Scientific American’s Science Talk, posted on February 20th, 2019. I’m Steve Mirsky.
Headline, The Guardian newspaper, February 12th: Measles Outbreak in Philippines Kills 70, with Vaccine Fearmongering Blamed.
Headline, CBS News, February 10th: Number of People with Measles Tripled in Europe in 2018, WHO says. In the article, this sentence: More than 82,000 people in Europe contracted the virus, which killed 72 people.
And again from CBS News, reporting from Washington State, this headline, February 8th: Hundreds Rally to Preserve Right not to Vaccinate Children amid Measles Outbreak. The rally is a response to a bill that would take away the state’s provision to allow parents to opt out of measles vaccines for kids for “philosophical reasons.” The good news there is that in the region where the outbreak has occurred, vaccine rates rose some 500 percent.
Before these headlines ran, there were other cases of outbreaks traced to unvaccinated kids. So I called Tara Smith. She’s an epidemiologist at Kent State University’s College of Public Health. In 2017 she published an article in the journal Open Forum Infectious Diseases titled “Vaccine Rejection and Hesitancy: A Review and Call to Action.” We spoke by phone.
Mirsky Why did you feel compelled to do this research and write this paper?
Tara Smith: So as part of my—I was a distinguished lecturer for the American Society for Microbiology, and so with that I would go to different branch meetings. So different meetings throughout the various states and give lectures. And one of the lectures that I gave commonly was a lecture on kind of science denial and especially vaccines. And what microbiologists could do about it. So I had people asking me, you know, after every lecture, "Have you ever written anything about this? Is there anything in the published literature that I could turn to?" And there really wasn't anything specifically for kind of people who were not physicians. So I thought it would be a good time to do a review and talk about things that other people could do to not maybe necessarily have patient contact every day.
Mirsky: And what are the things that other people can do?
Smith: Right. So there's a lot of different things depending, again, kind of on peoples' interests and expertise and time. I mean some of the simple things I think are just really making vaccines normalized. You know, still most people, even though there's this conception that vaccine hesitancy is growing, and in some ways it is, still most people get their children vaccinated on time and with the recommended schedule. But we don't really talk about it a lot. So I think one of the things to do is just if you get yourself or your child immunized, to post about it, you know, "My kid got their vaccines today." Next day maybe they had a little bit of a fever, maybe they were a little bit grumpy, or maybe they didn't have anything at all, they were just fine. So kind of normalizing vaccination instead of making it this kind of underground thing that you only hear about when people have a bad reaction, and so these are the normal, everyday vaccines that we don't hear about, that there's very little reaction to.
So that's one thing that anyone who gets a vaccination for themselves or their children can do.
You know, others are just talking to your legislators. So a lot of the laws regarding vaccines are set at the local and the state level, so if you get to know some of your politicians and see where they are on some of these issues, you know, you can write to them about your concerns about vaccines, about maybe reducing vaccine exemptions in your state. Most states still have exemptions for philosophical or religious beliefs in addition to medical exemptions.
You know, you can write letters to the editor. Those are still influential, even though we don't think maybe about, you know, paper newspapers as much every day and kind of opening up and reading the op eds, but those are online, those are widely shared, especially if they're, you know, anti-vaccine. So trying to do something to counter some of those anti-vaccine attitudes, just, you know, work to write a letter to the editor about your beliefs on vaccines and why you feel they're important.
So those are things that just about anyone can do to try to show support for vaccines and to really normalize them.
Mirsky: I just happened to be at a party the other day and I was talking to some parents from a town in New Jersey and they were talking about their local school board had just very loose requirements for asking for an exemption. Basically you could just say, "Well, it's against my religion." You didn't have to give any other information that would justify why you can get your kid out of the vaccine program. So is there, you know, the legislation—this gets into this very sticky area of what the government can tell you as a parent to do with your kids. But there is this public health factor where somebody else's kids getting vaccinated is necessary for the entire community's health. So, you know, how do you deal with that issue?
Smith: Right. And it is a tricky one. And sometimes it can depend, depending on, you know, state laws and differences between different states regarding who is exempted and public versus private schools. So, you know, I think the best thing to do, because again, I can't give a lot of universal advice because it does vary so much, is just get to know what your regulations are within the state, what your school district suggests, especially if they are public versus private, you know, know the rules there, and see what you can do to strengthen them. See if it's something that you do have to start with your individual school or if it's something that you have to take to the state legislature to get it changed there.
Mirsky: Now you talk in the article about the fact that vaccine rates—and you mentioned it earlier—they are still very high.
Mirsky: But we do see these pockets, these regional kind of situations where you have a lot of resistance. So as a general rule how would you categorize this problem? I mean we hear a lot about it, but is it really a huge problem?
Smith: I think it is, especially in some of those areas. So when we're talking about herd immunity we're talking about the amount of people in a population who need to be immune to block transmission of certain infections. And we usually use the term about 95-percent, because that's the level of immunity that we need to block the most infectious pathogen, which is measles. And so when you start getting it down below 95-percent you have these groups of individuals who are susceptible, especially to measles, and then if it gets lower they're susceptible as well to mumps and other organisms. So even though it's high overall, as you mentioned, we do have these pockets of areas that are well below 90-percent. In some cases you have communities where their vaccination rate may be at 60-percent or 50-percent, so they become very vulnerable to those infections when they're introduced from somebody from the outside.
So most of the outbreaks that we've seen over the past few years have been, you know, people who have been traveling to places where measles is endemic, which is a lot of, you know, for example, European countries. Go there for a vacation, they're not immunized, they come back to the United States and spread it to others in their communities. And it doesn't take very much—a large population to be unvaccinated to make the community susceptible to measles. So even though levels overall are pretty high, you know, we do have susceptibility to some of those introduced infections. And so I think that's the thing that we kind of need to be focusing on, is to try to keep those levels high and keep those really severe infections, like measles has the potential to be, out of our communities.
Mirsky: Now since you've written the paper we have seen some outbreaks. I mean there's one of the most noteworthy ones is in Minnesota among a Somali population that's been very effectively targeted by anti-vaccine activists.
Smith: Yes. Yeah. I mean that's one of the problems, is that trust is difficult. And so in that community Andrew Wakefield, who of course was one of the—a former British physician who was the first one to really put forward this idea linking the MMR vaccine specifically to autism, and so he went to this community to actually really stoke fear against vaccination, even while they were undergoing this epidemic. So it took a lot of really push by the public health community there, including people who were within the Somali community and that they already trusted to get them to start vaccinating and to put an end to that epidemic.
But it's hard. When that misinformation is in a community it spreads and it is really difficult to kind of reverse that fear and reverse that misinformation with accurate education. Once something that gets in there that it's incorrect it's really difficult to unring that bell.
Mirsky: And we should point out that Wakefield has lost his license to practice in England—
Smith: Yeah, multiple papers he's had retracted.
Mirsky: How bad is the situation today compared with what it's ever been? You mention in the paper that there seems to have been this increase of distrust in vaccination in the '90s. Is that really a measurable thing?
Smith: Right. It waxes and wanes and it's really difficult to get an idea on kind of the country as a whole, because it may increase in one area and decrease in another. And what you see is often that when you get these outbreaks that people in that area often see what happens and then you get at least a transient bump in immunization or you can get laws changed. I mean for California, for example, of course they had their measles outbreak associated with travel to Disneyland and that led to the introduction of SB277, which took away philosophical and religious exemptions for California students, leaving only medical exemptions. So that has led to an increase in vaccination rates throughout the state.
So these are the kinds of things we're seeing is you get these kinds of movements, but usually it takes an outbreak to get there. I mean we saw that in Ohio, too; we had, about the same time as Disneyland we had a large measles outbreak in our Amish population, who are not necessarily anti-vaccine, but usually don't get kind of routine vaccinations yearly like we do with our children. So public health individuals there did thousands of vaccinations over the course of a couple of weeks and got a lot of them caught up, but is that something that has stuck? You know, we don't really know if they're now getting their children vaccinated per like a CDC schedule or if it's kind of back to that same old, you know, kind of apathy about vaccination.
Mirsky: Mm-hmm. You mentioned writing to your newspaper or talking to your legislator to try to get your beliefs across. I think the word "belief" is really interesting here because, I mean, you and I, I think, share a belief that vaccines are completely positive, but our belief is rooted in measurable information that we know to be true, and the belief of an anti-vaccine person is not rooted in that same structure.
Smith: Right. And there's been a lot of research on that, looking at why people accept or refuse vaccines. And some of that has to do with values. I mean if you don't value Western medicine, if you don't value scientific research then you won't necessarily value vaccines as well; you may see them as, you know, a tool of the government, you know, something that medicine is doing to harm you instead of help you. So there's a lot of messiness that comes with accepting or denying vaccines. So even with that, you know, as I do mention in the paper as well, you know, it's not black and white; there's a whole spectrum of individuals who choose to vaccinate or not. Some may vaccinate selectively, they may vaccinate for things like the measles and some other routine childhood vaccinations, but don't vaccinate maybe for chicken pox or for influenza or HPV. So, you know, it's not something that is all or nothing and some of those beliefs and values come into play as well when it comes to those aspects.
Mirsky: Yeah, you know, I'm a little older than a lot of the audience probably, and I remember, you know, people say, "Well, we didn't have these seatbelt laws and we're all here." Yeah, those are the people who survived.
Smith: Right. Yeah.
Mirsky: The little kid who I was friends with when I was a little kid across the street was not wearing a seatbelt and he did not survive. A kid who was a block away from me when we were in grade school got meningitis and he did not survive. So, you know, I don't mean to sound like a grizzled war veteran, but I remember friends of mine as a kid dying from these preventable things. So, you know, and you do mention in the paper we're a victim of our own success in many ways.
Smith: Right. And that's how public health is in general. And again, lots of times it becomes invisible until there is some kind of an outbreak or, you know, in public health more generally some kind of crisis, a water crisis like in Flint, that calls peoples' attention to drinking water or, you know, outbreak of infectious disease. I mean look right now in Asheville, North Carolina, where you have a chicken pox outbreak.
I mean I also, I was the generation before the chicken pox vaccine, so I had that as a child, but I don't remember it as just a mild childhood disease; I was miserable. I was on the couch for over a week, I have scars on my face from it, my parents put two layers of socks on me and duct taped them to my arms so I would stop scratching all my scabs off. You know, I did survive it, but I knew I did not want my children to have to go through that. Even if there was a good chance they would survive, you know, they could end up hospitalized, they could end up with secondary infections. Before the vaccine 100 children a year died of chicken pox.
So it's something that is rare today, but it's rare because of the vaccine, and we're seeing that in North Carolina, that when you have a population with low vaccine coverage it can pretty easily come back.
Mirsky: Yeah. So, you know, these are such serious things, and when it's preventable it just feels even more tragic. And parents who have lost kids over preventable conditions because they didn't get a vaccination, it's just got to be the most heart wrenching thing to have to live with.
Smith: Right. Right. And that's why so many of them have started becoming advocates for vaccines. Once they see how sick their child got from a vaccine-preventable disease or they lost them to that disease, you know, they don't want others to go through that same thing.
Mirsky: And I don't know if we can say this enough times, but there is no evidence connecting vaccines with autism, there is no evidence that vaccines are dangerous in any way other than, you know, the usual—any intervention is going to have some small risk factor, but it's much—I mean you have to look at this at a population level, and so you are going to—on a population level you are going to save just so many lives using these interventions and you have to look at it statistically.
Smith: Yeah, and that's a hard thing for people, is that, you know, that risk calculus just doesn't come normal to people, right? The stories feel more real. So that's why, you know, of course it's flu season right now and every year in the United States somewhere between about 40 to 50 percent of people will get a flu shot. So that's a really big population. And serious reactions occur in maybe 1 in 1 million or so people, so again, they do exist, but they're really rare.
There's a story right now of a man in Nevada who has Guillain–Barré syndrome and it came on a few days after his flu shot. And so this story has gotten so much press, you know, this one man who developed a condition that may or may not have been caused by the flu shot.
Mirsky: Right. The proximity and time.
Smith: Yeah, ignoring all the people that got a flu shot and did not have anything happen, many millions—many millions and are protected by flu.
Mirsky: And other people who might've gotten Guillain–Barré without getting the flu shot.
Smith: Right. Exactly. Exactly.
Mirsky: Right. It's just a proximity thing; there's no evidence that that's the causal event, but, you know, that's the way our minds work, we're going to assign that to be the causal event. We should just tell people what Guillain–Barré is.
Smith: Right. So it's a neurological condition that can cause paralysis, sometimes temporary, sometimes it can be permanent. And it can be caused by infection; it can be caused by influenza infection. The most common cause of it is actually campylobacter infection, which is a food borne bacterium. But a lot of times the cause isn't easily determined, so it can be kind of mysterious and it can be scary, which is understandable. But these stories, you know, those are the ones that linger in peoples' minds, not all those people who got a flu shot and had no reaction, but this one man who got a flu shot and maybe had a condition afterwards that maybe was related to the flu shot.
Mirsky: Right. Just in case anybody's interested, the great writer, Joseph Heller, who wrote Catch 22, had a case of Guillain–Barré, and wrote a book about it along with—he had a friend, I think the friend's name was Speed Vogel, and the two of them wrote this book. Speed took care of Joseph Heller while he was recovering, during his almost year with the Guillain–Barré and the recovery. And the book about—'cause Joseph Heller was a funny guy, and Speed Vogel is also a funny guy, and the book, while giving you really useful info about this condition and describing life with it, is hilarious. So I really recommend—I wish I could remember the name of the book, but it's Joseph Heller and Speed Vogel and there are plenty of books out there about flu epidemics, the 1918 giant pandemic of the flu that just killed so many people, maybe 20 million people. Is that right?
Smith: Estimates put it up to 100 million, 50 [million] to 100 million.
Mirsky: Wow. So, you know, the thing I always tell people who are thinking about it is whether or not they should get vaccinated or vaccinate their kids, if you were in Africa right now in an area with Ebola and there was a vaccine that they were offering I think you would probably rush out to get it. But we live in such a relatively safe society that these things, again, we're victims of our own successes. We tend to just take these things for granted and we figure, "Well, there's no huge epidemic out there, so probably I don't have to do anything to avoid getting it."
But, you know, I'm a broken record, but geez, we're all in this together. I've gotten my flu shot; I get one every year.
Smith: Right. Right. And that's the thing, I mean we know the flu shot is not perfect, but we know that getting the flu shot, it helps reduce the risk of getting the infection. If you do get sick it reduces your risk of being hospitalized or dying from that. And that, you know, you don't come back from dying, right? So those are pretty serious things. So I get it every year knowing that it's not perfect, knowing that I might still get flu, but, you know, knowing that if I do it probably will be more mild than if I had not gotten that vaccine.
Mirsky: That's good. You don't come back from dying; I'm going to put that up there with my other favorite thing lately, which you see it on t-shirts and bumper stickers, "Vaccines cause adults."
Smith: Right. Yes. [laughs]
Mirsky: So what are you working on since this article came out?
Smith: We're still working on trying to do some studies to implement some of the things that we talked about in the article. So there have been some—a few articles out looking at some of the interventions by parents and by other scientists to discuss with vaccine-hesitant parents or parents-to-be some of the facts about vaccines and see if that helps sway them a little bit towards vaccination of their children. So we're trying to put together some studies with some physician collaborators to start testing some of these in a local area.
Mirsky: That's great stuff. I'm really glad I happened on your paper and had a chance to talk and I just think the kind of work you do is—you know, emergency room physicians are heroes and they save somebody's life and they may save, you know, a few peoples' lives every week, and then epidemiologists sit at a desk and they may save millions of lives. I think what epidemiologists like you do is just so important and I only wish there could be a TV show about your exploits.
Mirsky: But unfortunately it would just be you on the computer and the phone or lot.
Smith: Right. Maybe not so exciting for TV.
Mirsky: Right. But, you know, maybe going out to a site to interview people also. But yeah, it's not the same as ER, but it's just such vital work and I want to thank you for doing it and for taking the time to talk today.
Smith: Thank you, I appreciate you having me on.
Mirsky: That’s it for this episode. Get your science news at our Web site, www.scientificamerican.com. Where you can read Scott Barry Kaufman’s article titled Liberals and Conservatives Are Both Susceptible to Fake News, but for Different Reasons.
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