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Unvaccinated Children Trigger Measles Outbreak



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March 22, 2010

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VaccinesAn article published today (March 22, 2010) in the journal Pediatrics describes the reasons for the measles outbreak in San Diego in 2008.  Seventy-five percent of the children involved in this California outbreak were unvaccinated.  Multiple studies around the globe reflect the same risk to the unvaccined.  Measles can have very serious complications and it is estimated that in 2000 there were 733,000 measles related deaths worldwide.  All vaccinations have risks but they vary considerably depending upon the type of vaccine involved.

The chiropractic profession has been split over the vaccination issue.  A 2009 study of Alberta chiropractors found that  “92.6% had ever been immunized, but only 35.7% would accept immunization for themselves in the future. Further, 66.8% had at least one immunized child, and 21.8% indicated interest in referring patients for immunization.”  Again, the key is the relative risk associated with each specific immunization.  The responsible health care giver should provide balanced information to the patient so an informed decision can be made.

Measles Outbreak in a Highly Vaccinated Population, San Diego, 2008: Role of the Intentionally Undervaccinated

Published online March 22, 2010
PEDIATRICS (doi:10.1542/peds.2009-1653)


David E. Sugerman, MD, MPHa, Albert E. Barskey, MPHb, Maryann G. Delea, MPHc, Ismael R. Ortega-Sanchez, PhDb, Daoling Bi, MSb, Kimberly J. Ralston, MPHd, Paul A. Rota, PhDb, Karen Waters-Montijo, MPHd, Charles W. LeBaron, MDb

aEpidemic Intelligence Service, Office of Workforce and Career Development, and
bDivision of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
cCouncil of State and Territorial Epidemiologists, Atlanta, Georgia; and
dImmunizations Branch, County of San Diego Health and Human Services Agency, San Diego, California


Objective: In January 2008, an intentionally unvaccinated 7-year-old boy who was unknowingly infected with measles returned from Switzerland, resulting in the largest outbreak in San Diego, California, since 1991. We investigated the outbreak with the objective of understanding the effect of intentional undervaccination on measles transmission and its potential threat to measles elimination.

Methods: We mapped vaccination-refusal rates according to school and school district, analyzed measles-transmission patterns, used discussion groups and network surveys to examine beliefs of parents who decline vaccination, and evaluated containment costs.

Results: The importation resulted in 839 exposed persons, 11 additional cases (all in unvaccinated children), and the hospitalization of an infant too young to be vaccinated. Two-dose vaccination coverage of 95%, absence of vaccine failure, and a vigorous outbreak response halted spread beyond the third generation, at a net public-sector cost of $10376 per case. Although 75% of the cases were of persons who were intentionally unvaccinated, 48 children too young to be vaccinated were quarantined, at an average family cost of $775 per child. Substantial rates of intentional undervaccination occurred in public charter and private schools, as well as public schools in upper-socioeconomic areas. Vaccine refusal clustered geographically and the overall rate seemed to be rising. In discussion groups and survey responses, the majority of parents who declined vaccination for their children were concerned with vaccine adverse events.

Conclusions: Despite high community vaccination coverage, measles outbreaks can occur among clusters of intentionally undervaccinated children, at major cost to public health agencies, medical systems, and families. Rising rates of intentional undervaccination can undermine measles elimination.

Chiropractors and Vaccinations: Ethics is the Real Issue

COMPLEMENTARY HEALTH PRACTICE REVIEW 2009 JAN Vol. 14(1) pp. 36 - 50

Vernon, L.F.V.;  Kent, C.K.; 

This article traces the historical and philosophical roots of the provaccination and anti-vaccination movements through to the present day, with a focus on the role of chiropractic within those movements. Political, legal, and scientific issues are considered. Attempts to portray the anti-vaccination chiropractors as unscientific extremists, by both orthodox medicine and from within the chiropractic community itself, clouds the informed consent and freedom of choice aspect relating to health care that they espouse, and scapegoats the so-called extremists rather than facing the ethical issues surrounding fully informed consent. The authors conclude that would-be medical ethicists promote their own political agendas that aid profit before safety and breed distrust within the community that is meant to be served in a balanced and ethical manner.

Personal and professional immunization behavior among Alberta chiropractors: a secondary analysis of cross-sectional survey data.

JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS 2009 JUL-AUG Vol. 32(6) pp. 448 - 52

Medd, E.A.;  Russell, M.L.; 

OBJECTIVES: This study examined the relationship among chiropractors' personal immunization decisions, the vaccination status of their children, and their interest in referring patients for immunization.

METHODS: This was a secondary analysis of data collected in a 2002 postal survey of Alberta chiropractors (response rate, 78.2%). Analysis was restricted to chiropractors with children (n = 325). Chiropractors indicated their own vaccination status, that of their children, and their interest in referring patients for immunization. Data analysis included frequencies, cross tabulations, and logistic regression models (alpha = .05).

RESULTS: Most respondents were male (83.4%), had more than one child (71.8%), and had graduated from chiropractic college a median of 13 years before survey. Of the chiropractors, 92.6% had ever been immunized, but only 35.7% would accept immunization for themselves in the future. Further, 66.8% had at least one immunized child, and 21.8% indicated interest in referring patients for immunization. Chiropractors who would accept immunization for self in the future, compared with those who would not, were more likely to indicate interest in patient referral for immunization (odds ratio, 11.4; 95% confidence interval, 5.4-24.0; P < .001). Chiropractors who have at least one immunized child, compared with those with none immunized, were 6.2 times more likely to indicate interest in referring patients for immunization (odds ratio, 6.2; 95% confidence interval, 1.4-28.4; P = .018).

CONCLUSIONS: Alberta chiropractors are consistent in their personal and professional behaviors. Chiropractors who accept vaccinations for themselves or their children are more likely to refer patients to public health for immunizations.

Factors Associated with Changes in Knowledge and Attitude towards Public Health Concepts among Chiropractic College Students Enrolled in a Community Health Class.

JOURNAL OF CHIROPRACTIC EDUCATION 2008 FAL Vol. 22(2) pp. 127 - 37

Rose, K.A.;  Ayad, S.; 

PURPOSE: This survey was conducted to identify factors that may be associated with changes in knowledge and attitudes towards basic health promotion and public health concepts among chiropractic students enrolled in a course in community health.

METHODS: Anonymous surveys were conducted of students before and after a second-year chiropractic college course in community health. Results were analyzed using percentages and Chi Square statistics as appropriate.

RESULTS: Students' knowledge of health promotion and public health concepts improved significantly by the end of the course. Students' attitudes towards these also improved, although to a lesser degree. Students indicated that they had a favorable impression of the importance of utilizing health promotion in practice and working with other public health professionals. However, vaccinations were still looked upon unfavorably by half of the students by the end of the course. Pre-class, a positive attitude towards public health concepts was associated with being female, older, Latino, having children, having a poorer perceived health status, conservative politically and religious. These differences tended to lessen by the end of the course.

CONCLUSION: A course in community health was successful in adding to students' knowledge and positive attitudes towards health promotion and public health. However, additional educational strategies are needed to ensure changes in future practice behavior, particularly in the area of vaccinations.

Vaccination Is Both Beyond and Consistent with Chiropractic Philosophy!

JOURNAL OF THE AMERICAN CHIROPRACTIC ASSOCIATION 2008 DEC Vol. 45(9)

Cooperstein, R.; 

Dr. Robert Cooperstein explains the reasoning he gives students for supporting the concept of vaccination.

Canadian chiropractors' perception of educational preparation to counsel patients on immunization.

JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS 2006 OCT Vol. 29(8) pp. 643 - 50

Injeyan, H.S.;  Russell, M.L.;  Verhoef, M.J.;  Mutasingwa, D.; 

OBJECTIVE: This study describes the prevalence and correlates of perceptions of Canadian doctors of chiropractic regarding the adequacy of their undergraduate (UG) and postgraduate (PG) educational preparation to counsel patients about immunization/vaccination and explores their preferences for continuing education (CE) in this area.

METHODS: A cross-sectional population-based postal survey of Alberta chiropractors was conducted in the summer of 2002.

RESULTS: The response rate was 78.2%. Forty-five percent perceived that their formal UG chiropractic education prepared them adequately to counsel people on immunization compared with 64% who agreed that their self-directed PG education prepared them adequately. College of graduation was significantly associated with perceptions related to UG but not PG education. Those who felt prepared to counsel on immunization by UG education used different immunization information sources than those who felt prepared by PG or both UG and PG education. Use of specific sources and perception of preparedness to counsel on immunization were both associated with antivaccination behaviors. Those who felt prepared by PG or both UG and PG education were more likely to engage in antivaccination behavior than others. Most respondents indicated interest in CE on immunization.

CONCLUSION: The proportion of doctors of chiropractic who perceive themselves adequately prepared to counsel on immunization varies by type of education considered and is related to vaccination behavior. Many are interested in some form of CE related to immunization/vaccination.

Immunization and the chiropractor-patient interaction: a Western Canadian study.

JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS 2006 FEB Vol. 29(2) pp. 156 - 61

Page, S.A.;  Russell, M.L.;  Verhoef, M.J.;  Injeyan, H.S.; 

OBJECTIVE: To explore how the topic of vaccination arises during interactions between chiropractors and their patients, the advice that is given to patients, and the factors that influence the opinions of the chiropractors.

METHODS: Data were collected in semistructured interviews with a purposeful sample of chiropractors in Calgary, Canada. Data were analyzed using qualitative content analysis and constant comparison. Participants were chiropractors who had participated in a postal survey of immunization-related beliefs and behaviors and who consented to contact for further study.

RESULTS: Data redundancy was attained after 14 interviews were complete. Immunization arose in clinical encounters by both indirect (provision of reference materials and/or posting of media stories in clinic waiting rooms) and direct communication. Direct communications were most commonly patient initiated and were prompted by media reports, clinic waiting room material, or patient perceived adverse reactions; however, they were also initiated by the chiropractors, particularly if they were seeing young children with their parents. For some chiropractors, the emphasis was on providing information of a negative, antivaccination nature; others referred clients to physicians and nurses. Factors that influenced their opinions included their chiropractic training, philosophy of health and illness, and self or important others having experienced negative reactions that were perceived to result from immunization.

CONCLUSIONS: Both patients and chiropractors initiate discussions on immunization in practice, with many chiropractors using indirect stimuli to open the topic. Doctors of chiropractic in this particular sample were heterogeneous with respect to the information provided to patients. However, study findings may not be generalizable outside Canada.

What's Good for the Goose Is ... Ethics and Vaccinations

DYNAMIC CHIROPRACTIC 2005 FEB Vol. 23(4)

Perle, S.;  Ferrance, R.; 

There appear to be many in our profession who are opposed to mandatory vaccination. A recent study conducted in the Canadian Province of Alberta found that 27.2% of the doctors of chiropractic who completed the survey encouraged/advised their patients against having themselves or their children immunized.1 The authors of the study, Russell, et al., concluded that there is great heterogeneity among our profession's behaviors regarding immunization, similar to everything else in chiropractic. We believe that there are a variety of subtypes within the profession regarding immunizations. There are those that are driven by libertarian political philosophy, whose opposition is purely to government's control over our health. Some have a basic reluctance to use vaccines as part of their general reluctance to use any medication. This reluctance is consistent with our profession's philosophical belief in naturalism and therapeutic conservatism.2 These chiropractors appear to us to be the least strident in their opposition to the use of vaccination, and we suspect, rarely suggest to patients that they should avoid vaccinations.

Spotlight on measles 2010: measles outbreak in Ireland 2009-2010.

Gee S, Cotter S, O'Flanagan D; National Incident Management Team.
HSE-Health Protection Surveillance Centre, Dublin, Ireland.

Measles cases are increasing in Ireland, with 320 cases notified since August 2009. Nearly two-thirds of these cases (n=206) were unvaccinated. In the early stages of the outbreak a substantial number of cases were linked to the Traveller community with some cases also reported among the Roma community, other citizens from eastern Europe and children whose parents objected to vaccination. By February 2010, there had been considerable spread to the general population.

Measles: not just a childhood rash.

Cleve Clin J Med. 2010 Mar;77(3):207-13.

Sabella C.
Center for Pediatric Infectious Diseases, Cleveland Clinic Children's Hospital, Cleveland, OH 44195, USA. sabellc@ccf.org

In recent years, the number of US measles cases has increased, and outbreaks in adults continue to be reported in communities with a high number of unvaccinated people. These trends underscore the need for high overall measles vaccination coverage, and for physicians to entertain the diagnosis of measles in adult patients with a febrile illness and rash.

Global measles mortality, 2000-2008.

MMWR Morb Mortal Wkly Rep
. 2009 Dec 4;58(47):1321-6.

Centers for Disease Control and Prevention (CDC).

The United Nations (UN) Millennium Development Goals include a goal (MDG 4) to achieve a two thirds overall reduction of child deaths by 2015 compared with the 1990 level. Because many unvaccinated children die from measles, routine measles vaccination coverage is used as an indicator of progress toward this goal. In 2008, all UN member states reaffirmed their commitment to achieving a 90% reduction in measles mortality by 2010 compared with 2000, from an estimated 733,000 deaths in 2000 worldwide to <73,300 by 2010. The World Health Organization (WHO) and UNICEF have identified 47 priority countries with the highest burden of measles for an accelerated strategy for measles mortality reduction. The strategy includes 1) achieving and maintaining high coverage (>or=90% nationally and >or=80% in each district) with 2 doses of measles-containing vaccine (MCV) delivered through routine services or supplemental immunization activities (SIAs) , 2) implementing effective laboratory-supported disease surveillance, and 3) providing appropriate clinical management for measles cases. This report updates a previously published report, provides details on activities implemented during 2008, assesses progress toward the 2010 goal, and evaluates the potential effects of decreased financial support. During 2000--2008, global measles mortality declined by 78%, from an estimated 733,000 deaths in 2000 to 164,000 in 2008, but the reduction in measles mortality has been leveling off since 2007. To reach the 2010 goal, India should fully implement the recommended strategies, and financial support for sustaining measles control in the other 46 priority countries should be secured.

Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases.

N Engl J Med. 2009 May 7;360(19):1981-8.

Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N.
Hubert Department of Global Health, Rollins School of Public Health and the Emory Vaccine Center, Emory University, Atlanta, GA 30322, USA. somer@emory.edu

Vaccines are among the most effective prevention tools available to clinicians. However, the success of an immunization program depends on high rates of acceptance and coverage. There is evidence of an increase in vaccine refusal in the United States and of geographic clustering of refusals that results in outbreaks. Children with exemptions from school immunization requirements (a measure of vaccine refusal) are at increased risk for measles and pertussis and can infect others who are too young to be vaccinated, cannot be vaccinated for medical reasons, or were vaccinated but did not have a sufficient immunologic response. Clinicians can play a crucial role in parental decision making. Health care providers are cited as the most frequent source of immunization information by parents, including parents of unvaccinated children. Although some clinicians have discontinued or have considered discontinuing their provider relationship with patients who refuse vaccines, the American Academy of Pediatrics Committee on Bioethics advises against this and recommends that clinicians address vaccine refusal by respectfully listening to parental concerns and discussing the risks of nonvaccination. 2009 Massachusetts Medical Society

Measles resurgence in France in 2008, a preliminary report.

Euro Surveill
. 2009 Feb 12;14(6). pii: 19118.

Parent du Châtelet I, Floret D, Antona D, Lévy-Bruhl D.
Institut de Veille Sanitaire (InVS), French Institute for Public Health Surveillance, France. i.parent@invs.sante.fr

Since the beginning of 2008, France is experiencing a resurgence of measles. It started in a religious traditionalist group with low coverage and secondarily spread to the general population. This situation is the consequence of the insufficient vaccine coverage (less than 90 % at 24 months of age) which had led to the accumulation of susceptibles over the last years. More than 550 cases have been notified in 2008, the vast majority being unvaccinated. One measles-related death has occurred early 2009. Efforts to enhance communication to the general public and the health professionals on measles vaccination and control measures around cases are ongoing.
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