Outbreak?

03.30.13

Why Rubella’s Scary Comeback Should Convince Vaccine Deniers

The CDC reported three German measles cases in newborns from unvaccinated mothers in 2012. It’s the best evidence yet of why vaccines are in the interest of public health, if conspiracy theorists are even listening.

There was a mighty scary public-health story out this week, one that suggests a new and real danger looming across America.

No, not the sad tale of the Tulsa dentist, he of the rusty instruments, unqualified assistants, and apparently tone-deaf responses to investigators (Click here for an appointment). A lot of blood tests will be drawn, blood pressures raised, and lawsuits filed— but time will show that little harm will have been visited upon the public’s health.

The real public-health story has attracted no media attention. This week, the Centers for Disease Control and Prevention reported that three cases of congenital rubella (aka German measles) had occurred in 2012 in the U.S., the first such cases since 2008.

The control of rubella and its single dreaded complication, congenital rubella syndrome (CRS), is one of the triumphs of vaccination specifically and public health in general. For the non-pregnant, rubella causes a mild illness—a little fever, a little rash—and seldom is sufficiently severe to warrant a doctor visit. In pregnant women though, particuarly those in the early weeks, the results can be devastating to the fetus. In 1964-65, America had a major rubella epidemic, with more than 12 million cases and 20,000 babies born with congenital rubella; of these, 13,000 were deaf, 3,500 were blinded by congenital cataracts, and 1,800 more suffered severe cognitive impairment.

By 1969, a vaccine was developed and soon everyone—not just pregnant women but everyone—was vaccinated, with rapid and impressive results: cases immediately began to drop. To simplify matters, in 1971, the rubella vaccine, a live attenuated (weakened) virus, was combined with the similarly live and attenuated strains of two other ubiquitous viral infections, measles and mumps, to constitute “MMR,” a vaccine given to infants, children, and young adults.

Recent outbreaks of mumps in New York and New Jersey among mostly vaccinated orthodox Jewish children and of measles in people who attended Super Bowl parties in Indianapolis 14 months ago have served as a bracing reminder that these diseases are anything but gone, even in the U.S., where schools mandate vaccination—to the horror of hipsters and vaccine conspiracy theorists, as well as a few stray libertarians outraged at any attempt to direct an individual for the greater public good.

So too with rubella: the U.S. was certified as rubella-free in 2004, meaning that no cases were seen in persons residing here. However, importation cases—cases from people traveling to the U.S. who hail from areas of the world without adequate vaccine programs—have continued, with about nine reported each year reported to the CDC.  It is noteworthy too that there’s an outbreak of rubella in Japan, including in Tokyo, where vaccine programs are in place and public-health coffers are plentiful. The reason for the Japanese outbreak is under investigation; it is uncertain whether it relates to lapses, avoidance of vaccination, or other factors.

What chance does objective evidence of the horrors of a poor vaccination program have when placed against the ever-growing neglect of reality that characterizes the anti-vaccine movement?

The mothers of the three infants with congenital rubella were from African countries (Tanzania, Nigeria, and the Sudan) prior to delivering babies in Maryland, Alabama, and Illinois, respectively. None appear to have been vaccinated against rubella. One of the infants died of congenital disease while the other two have severe congenital abnormalities. Each child represents a vaccine-preventable tragedy.

Those who think this might be information relevant only to the people who care about immigrants and immigrant health should take note of a unique and unsettling feature of congenital rubella. The usual period of contagiousness with rubella is a few days, generally overlapping the period that the characteristic mild rash and fever are present. But for infants with congenital disease, the period of viral shedding and contagiousness can extend month after month. Thus the infants likely exposed countless health-care workers to large amounts of rubella virus.

Thankfully, however, it appears that the health-care workers involved in the infants’ care had been vaccinated, as many states require for hospital workers, because no secondary transmission to them has been described. Thus not only the workers but their families are being provided the benefit of the heavy-handed American health-care system, which requires vaccines for the public’s health (take that, libertarians and anti-vaccine enthusiasts). As with all infectious diseases, it only takes one transmission to set up a series of events that could soon become a substantial public-health problem; as evidenced by the mumps and measles outbreaks in the U.S., or Japan’s problem with rubella, these diseases only need a small break in our collective vaccine-induced immune shell to spread quickly.

Beyond the sadness for the families whose lives were shattered by congenital rubella is the assuring-if-boring story of public health performing according to plan. But what chance does objective evidence of the horrors of a poor vaccination program have when placed against the ever-growing neglect of reality that characterizes the anti-vaccine movement?

It is impossible to argue with those whose willful ignorance excludes examination of basic facts. It is likely that the tragedy of these three children, similar to the children who died at Sandy Hook Elementary, will not advance rational discussions about assuring public safety, but rather will be quickly discarded by single-minded zealots obsessed with perpetuating an argument that long ago lost touch with the real world.