REBEL Cast
REBEL Cast
Salim R. Rezaie, MD
REBEL Core Cast 43.0 – Measles + Antivax
25 minutes Posted Oct 28, 2020 at 7:00 am.
X19862949. Published 2019 Jul 24.
X19862949. Published 2019 Jul 24.Â
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Show notes
Take Home Points
Measles is highly infective: One infected person can infect approximately 10-20 unvaccinated people
2 doses of MMR is 97% protective
Unvaccinated people can acquire measles from travel to endemic areas with low vaccination rates
There is a large amount of misinformation on the internet
Misinformation uses fear based messaging and the power of story
The evidence is overwhelming > 23,000,000 patients showing no evidence of any link between autism and MMR
Anecdotes are not evidence but vulnerable patients may be more susceptible to story then statistics
We should add anecdote as a tool to counsel patients
REBEL Core Cast 43.0 – Measles + Antivax
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Measles Review:
R◦ 9-18:  One infected person can infect approximately 10-20 unvaccinated people
Transmitted via respiratory droplets
Aerosolized viral particles remain in the air for 2 hours
Exposed people who are not immune have a 90% chance at becoming infected
Incubation period of 10-14d from the day of first exposure
Patients 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 syndrome
Classic features are cough, coryza, conjunctivitis, maculo-papular rash
Rash spreads from head to trunk and extremities and resolves the same way
Koplick spots are grayish blue lesions on the oral mucous which are present in 70% are pathognomonic
Measles Epidemiology and New Outbreaks:
We can prevent and eradicate measles
2 doses of MMR is 97% protective
Easily diagnosable clinical syndrome
No animal reservoir
Vaccine first licensed in 1963 and measles rapidly declined
Prior to immunization estimated 2-3 million deaths globally per year
Still leading cause of vaccine preventable death (>100,000 deaths/year globally)
Requires 90-95% vaccine coverage to maintain herd immunity
In 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 vaccination
Rise 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 states
503 of 704 (71%) were unvaccinated
6 of 13 were close knit non-immunized communities
Unvaccinated people can acquire measles from travel to endemic areas with low vaccination rates
Outbreaks driven by vaccine misinformation
Anti-Vaccine movement:
1998 Lancet case series of 12 patients reported enterocolitis linked to regressive autism triggered by MMR vaccine
Patients were recruited through anti-MMR campaigners
Study commissioned and funded with plan for lawsuit against pharmaceutic companies
Data was manipulated and falsified to fit this narrative to support the lawsuit
Article was retracted and the principle author lost his license
BUT THE DAMAGE WAS DONE
Internet and Social Media Evidence:
Youtube videos about immunizations: 32% opposed vaccinations
Anti vaccination videos had higher ratings and more views than pro-vaccine videos
Google search study: Analyzed content of the first 100 sites found after typing in “vaccination” and “immunization” Into Google
43% of the websites were anti-vaccination
Twitter study: 50% of tweets about vaccination contain anti-vaccine beliefs
Celebrities and elected public official use social media to spread misinformation about vaccines
Vulnerable people believe their status gives them access to information the average person might not have
Parents link autism and other diseases to “vaccine injury”
Share stories on anti-vaccine blogs and discussion boards to “warn” other parents
Stoke fear in parents that vaccines are dangerous without accurate info to refute claims
Article in Vaccine in 2008: 5-10 minutes on anti-vaccine site can increase perceptions of vaccine risks and decrease perceptions of risks of avoiding vaccines
perceptions persisted 5 months later
children of these parents receive less vaccines
Non-medical exemption (NME):
18 states allow for non medical exemptions
High number of NMEs in some densely populated areas (Washington, texas)
Vaccine preventable diseases could originate and spread rapidly through these areas
A child with NME for MMR is 35x more likely to contract measles
NMEs weaken herd immunity
What are parents’ concerns?
Vaccine 2007
oversights
socioeconomic barriers: low income, multiple children
health care may be divided across providers
Religious or personal exemptions
Medical exemptions
Some Anti Vaccine beliefs
Children receive too many vaccines in total
Children receive too many vaccines at one time
Vaccines are unsafe
Vaccines have long term negative health effects
Vulnerable parents seek additional information
May use the Internet rather than ask their doctor
Searches led to both public health and anti-vaccination sites
Evidence Based Medicine:
Meta analysis Vaccine in 2014
more than 1.2 million patients
no evidence for association between autism, ASD and vaccination or any components such as thimersol or mercury
2019: ANNALS OF INTERNAL MEDICINE:
6517 cases and 650,000 patients
Largest single study ever conducted
More than 5,000,000 person years of follow up
Repeat of similar study by same group which did not overlap with another >500,000 patients
No evidence of increased risk of autism after MMR vaccine
No evidence MMR triggers autism in susceptible subgroups
No evidence for clustering of of cases in specific time periods —> autism overnight
This Cochrane Review was published in April of 2020
Included 138 studies (23,480,668 participants)
Vaccines did not cause autism or any other suspected unwanted effect.
Small risks of febrile seizures and ITP
Counseling Patients on misinformation
Anti-vaccination movement has a better and more compelling story
Medical websites, statistics, vaccine fact sheet may not be enough
Stories can make information easily understandable for patients
Stories penetrate more deeply then just numbers and stats
Use clinical experience where we care for patients with these vaccine preventable diseases
Many doctors are parents face the same vaccine decisions
highlight the reasons we chose to vaccinate
Vaccine ambassadors: other parents who vaccinate
Pro-vaccine blogs for those who prefer this type of info
Presentation Zen: don’t leave the numbers hanging
Use numbers in a way parents can understand
For example Instead of percentages… maybe more effective to say one child in you kids class will be affected by this disease
RESONATE: “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 way
How 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 sincerely
Give them a fine reputation to live up to
Be a good listener and encourage people to talk about themselves
Be sympathetic with the other person’s ideas and desires
Get 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, Gasta̱aduy P, et al. Notes from the Field: Community Outbreak of Measles РClark 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 Jul
Benecke 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.298.21.2482
Davies P, Chapman S, Leask J. Antivaccination activists on the world wide web. Arch Dis Child. 2002;87(1):22-25. doi:10.1136/adc.87.1.22
Hussain 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:10.1177/1359105309353647
Downs JS, de Bruin WB, Fischhoff B. Parents’ vaccination comprehension and decisions. Vaccine. 2008;26(12):1595-1607. doi:10.1016/j.vaccine.2008.01.011
Olive 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/NEJMcp1905181
Taylor 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.2014.04.085
Hviid A, Hansen JV, Frisch M, Melbye M. Measles, Mumps, Rubella Vaccination and Autism. Ann Intern Med. 2019;171(5):388. doi:10.7326/L1-0383
Di 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.pub4
Shelby 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. 2010
Post 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.