Take Home PointsMeasles is highly infective: One infected person can infect approximately 10-20 unvaccinated people2 doses of MMR is 97% protectiveUnvaccinated people can acquire measles from travel to endemic areas with low vaccination ratesThere is a large amount of misinformation on the internetMisinformation uses fear based messaging and the power of storyThe evidence is overwhelming > 23,000,000 patients showing no evidence of any link between autism and MMRAnecdotes are not evidence but vulnerable patients may be more susceptible to story then statisticsWe should add anecdote as a tool to counsel patientsREBEL Core Cast 43.0 – Measles + AntivaxClick here for Direct Download of PodcastMeasles Review:R◦ 9-18:  One infected person can infect approximately 10-20 unvaccinated people Transmitted via respiratory dropletsAerosolized viral particles remain in the air for 2 hoursExposed people who are not immune have a 90% chance at becoming infectedIncubation period of 10-14d from the day of first exposurePatients are contagious 4 days before classic rash and 4 days after onset of rash (approximately 8 days total)Patients can shed the virus before we can distinguish the illness a typical viral syndromeClassic features are cough, coryza, conjunctivitis, maculo-papular rashRash spreads from head to trunk and extremities and resolves the same wayKoplick spots are grayish blue lesions on the oral mucous which are present in 70% are pathognomonicMeasles Epidemiology and New Outbreaks:We can prevent and eradicate measles2 doses of MMR is 97% protectiveEasily diagnosable clinical syndromeNo animal reservoirVaccine first licensed in 1963 and measles rapidly declinedPrior to immunization estimated 2-3 million deaths globally per yearStill leading cause of vaccine preventable death (>100,000 deaths/year globally)Requires 90-95% vaccine coverage to maintain herd immunityIn 2000 US eradicated measles with high vaccine coverage (no sustained transmission of virus for more than 12 months)Estimated 21 million deaths prevented worldwide since 2000 due to vaccinationRise in new measles outbreaks (31% increase from 2016 and 2017)704 cases since January 2019 (Largest number since measles declared eradicated)13 outbreaks involving 22 states503 of 704 (71%) were unvaccinated6 of 13 were close knit non-immunized communitiesUnvaccinated people can acquire measles from travel to endemic areas with low vaccination ratesOutbreaks driven by vaccine misinformationAnti-Vaccine movement:1998 Lancet case series of 12 patients reported enterocolitis linked to regressive autism triggered by MMR vaccinePatients were recruited through anti-MMR campaignersStudy commissioned and funded with plan for lawsuit against pharmaceutic companiesData was manipulated and falsified to fit this narrative to support the lawsuitArticle was retracted and the principle author lost his licenseBUT THE DAMAGE WAS DONEInternet and Social Media Evidence:Youtube videos about immunizations: 32% opposed vaccinationsAnti vaccination videos had higher ratings and more views than pro-vaccine videosGoogle search study: Analyzed content of the first 100 sites found after typing in “vaccination” and “immunization” Into Google43% of the websites were anti-vaccinationTwitter study: 50% of tweets about vaccination contain anti-vaccine beliefsCelebrities and elected public official use social media to spread misinformation about vaccinesVulnerable people believe their status gives them access to information the average person might not haveParents link autism and other diseases to “vaccine injury” Share stories on anti-vaccine blogs and discussion boards to “warn” other parentsStoke fear in parents that vaccines are dangerous without accurate info to refute claimsArticle in Vaccine in 2008: 5-10 minutes on anti-vaccine site can increase perceptions of vaccine risks and decrease perceptions of risks of avoiding vaccinesperceptions persisted 5 months later children of these parents receive less vaccinesNon-medical exemption (NME):18 states allow for non medical exemptionsHigh number of NMEs in some densely populated areas (Washington, texas)Vaccine preventable diseases could originate and spread rapidly through these areasA child with NME for MMR is 35x more likely to contract measlesNMEs weaken herd immunityWhat are parents’ concerns?Vaccine 2007oversightssocioeconomic barriers: low income, multiple childrenhealth care may be divided across providersReligious or personal exemptionsMedical exemptionsSome Anti Vaccine beliefsChildren receive too many vaccines in totalChildren receive too many vaccines at one timeVaccines are unsafeVaccines have long term negative health effectsVulnerable parents seek additional information May use the Internet rather than ask their doctorSearches led to both public health and anti-vaccination sitesEvidence Based Medicine:Meta analysis Vaccine in 2014more than 1.2 million patientsno evidence for association between autism, ASD and vaccination or any components such as thimersol or mercury2019: ANNALS OF INTERNAL MEDICINE:6517 cases and 650,000 patients Largest single study ever conductedMore than 5,000,000 person years of follow up Repeat of similar study by same group which did not overlap with another >500,000 patientsNo evidence of increased risk of autism after MMR vaccineNo evidence MMR triggers autism in susceptible subgroupsNo evidence for clustering of of cases in specific time periods —> autism overnight This Cochrane Review was published in April of 2020Included 138 studies (23,480,668 participants)Vaccines did not cause autism or any other suspected unwanted effect.Small risks of febrile seizures and ITPCounseling Patients on misinformationAnti-vaccination movement has a better and more compelling storyMedical websites, statistics, vaccine fact sheet may not be enoughStories can make information easily understandable for patientsStories penetrate more deeply then just numbers and statsUse clinical experience where we care for patients with these vaccine preventable diseasesMany doctors are parents face the same vaccine decisionshighlight the reasons we chose to vaccinateVaccine ambassadors: other parents who vaccinatePro-vaccine blogs for those who prefer this type of infoPresentation Zen: don’t leave the numbers hangingUse numbers in a way parents can understandFor example Instead of percentages… maybe more effective to say one child in you kids class will be affected by this diseaseRESONATE: “Greatest stories of all time are packaged and transferred so well that hundred of illiterate generations could repeat them”Hero’s journey: “You are not the hero” in this story the parents are the hero We are mentors along the wayHow to win friends and influence people:Remember that a person’s name is to that person the sweetest and most important sound in any language.Make the other person feel important – and do it sincerelyGive them a fine reputation to live up toBe a good listener and encourage people to talk about themselvesBe sympathetic with the other person’s ideas and desiresGet the other person saying ‘yes, yes’ immediately.”Any fool can criticize, complain, and condemn—and most fools do. But it takes character and self-control to be understanding and forgiving.References:Paules CI, Marston HD, Fauci AS. Measles in 2019 – Going Backward. N Engl J Med. 2019;380(23):2185-2187.Patel M, Lee AD, Redd SB, et al. Increase in Measles Cases – United States, January 1-April 26, 2019. MMWR Morb Mortal Wkly Rep. 2019;68(17):402-404. Published 2019 May 3.Carlson A, Riethman M, Gastañaduy P, et al. Notes from the Field: Community Outbreak of Measles – Clark County, Washington, 2018-2019. MMWR Morb Mortal Wkly Rep. 2019;68(19):446-447. Published 2019 May 17.McDonald R, Ruppert PS, Souto M, et al. Notes from the Field: Measles Outbreaks from Imported Cases in Orthodox Jewish Communities – New York and New Jersey, 2018-2019. MMWR Morb Mortal Wkly Rep. 2019;68(19):444-445. Published 2019 May 17.Hussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018;10(7):e2919. Published 2018 JulBenecke O, DeYoung SE. Anti-Vaccine Decision-Making and Measles Resurgence in the United States. Glob Pediatr Health. 2019;Keelan J, Pavri-Garcia V, Tomlinson G, Wilson K. YouTube as a source of information on immunization: a content analysis. JAMA. 2007;298(21):2482-2484. doi:10.1001/jama.298.21.2482Davies P, Chapman S, Leask J. Antivaccination activists on the world wide web. Arch Dis Child. 2002;87(1):22-25. doi:10.1136/adc.87.1.22Hussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018;10(7):e2919. Published 2018 Jul 3.Benecke O, DeYoung SE. Anti-Vaccine Decision-Making and Measles Resurgence in the United States. Glob Pediatr Health. 2019;Betsch C, Renkewitz F, Betsch T, Ulshöfer C. The influence of vaccine-critical websites on perceiving vaccination risks. J Health Psychol. 2010;15(3):446-455. doi:10.1177/1359105309353647Downs JS, de Bruin WB, Fischhoff B. Parents’ vaccination comprehension and decisions. Vaccine. 2008;26(12):1595-1607. doi:10.1016/j.vaccine.2008.01.011Olive JK, Hotez PJ, Damania A, Nolan MS. The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties [published correction appears in PLoS Med. 2018 Jul 6;15(7):e1002616]. PLoS Med. 2018;15(6):e1002578. Published 2018 Jun 12.Strebel PM, Orenstein WA. Measles. N Engl J Med. 2019;381(4):349-357. doi:10.1056/NEJMcp1905181Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32(29):3623-3629. doi:10.1016/j.vaccine.2014.04.085Hviid A, Hansen JV, Frisch M, Melbye M. Measles, Mumps, Rubella Vaccination and Autism. Ann Intern Med. 2019;171(5):388. doi:10.7326/L1-0383Di Pietrantonj C, Rivetti A, Marchione P, Debalini MG, Demicheli V. Vaccines for measles, mumps, rubella, and varicella in children. Cochrane Database Syst Rev. 2020;4(4):CD004407. Published 2020 Apr 20. doi:10.1002/14651858.CD004407.pub4Shelby A, Ernst K. Story and science: how providers and parents can utilize storytelling to combat anti-vaccine misinformation. Hum Vaccin Immunother. 2013;9(8):1795-1801.Reynolds, Garr. Presentation Zen : Simple Ideas on Presentation Design and Delivery. Berkeley, CA: New Riders, 2012.Carnegie, Dale, 1888-1955. How To Win Friends and Influence People. New York: Simon & Schuster, 2009.Duarte, Nancy. Resonate. Hoboken, NJ. 2010Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)The post REBEL Core Cast 43.0 – Measles + Antivax appeared first on REBEL EM - Emergency Medicine Blog.