American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, February 19, 2015

Measles in the Magic Kingdom? It's a small world, after all

One would think our recent experience with Ebola, the rapid and predictable, albeit, rare transmission of the disease out from its site of origin to far-flung places around the globe, including here, and the attendant hysteria, would have taught us already that when it comes to infectious diseases, it's a small world after all. With a human population well in excess of 7 billion filling global nooks and crannies, and modern technology to get our stories from here to there all but instantaneously, and ourselves only a bit slower than that, it's a small world after all. It's a small, small world.

But on the chance we did not indelibly get that memo from the still simmering Ebola calamity in West Africa, perhaps we will get it now that measles is propagating rapidly outward from an index case at Disneyland.

The story, as we know it thus far, is that measles was transmitted at Disneyland and Disney's California Adventure Park, by 1 or more infected visitors around mid-December. Measles is a highly infectious viral disease, and has thus predictably spread to 5 states and 2 countries from the inception of the outbreak in California. News outlets are reporting 59 confirmed cases thus far, although the news, fast as it is, is unlikely to keep up with the spread of this disease, and there are apt to be others who already have it but are as yet undiagnosed.

We don't know the status of all outbreak victims thus far, but of the 34 cases in California, 28 were unvaccinated.

That is of profound importance for 2 reasons.

The first, and obvious 1, is that immunization against measles is highly effective, so predictably in any outbreak the victims are disproportionately the unvaccinated. They chose to play Russian roulette, with their own health and/or that of their children, and lost.

The second, though, may be just a bit less blatant. Since thus far 6 of the 34 infected in California were fully or partially immunized, this outbreak tells us that the best defense against an infectious disease is not just immunity against it, but rather the combination of immunity against, and the unlikelihood of encountering it at all, because everyone else is immune, too.

No matter how effective a vaccine is, the strength of the immune response can wane with time. Routine booster vaccines can compensate for this, but obviously won't do so if they are forgotten. If viruses mutate slightly over time, that might also help them overcome a vintage vaccine.

The implication, I think, is obvious. If you choose to avoid standard, recommended vaccines such as measles, you are not merely putting your own health at risk, you are choosing to do the same for all the rest of us. Sorry, folks, but that's the harsh reality. There is an obligation at times to think beyond our own skin. However much we admire the brave health professionals who treat Ebola in West Africa, we want to be certain they honor all of the safety protocols and quarantine, to protect us. That, too, is part of their mission: precautions to prevent spreading the disease to innocent bystanders.

What's good for the goose is good for the gander. The unimmunized who not only acquired measles, but spread it, are quite analogous to someone dodging their Ebola quarantine, and taking chances with the health of all around him or her. Except, of course, the measles scenario is in a way far worse, since the folks acquiring measles did not do so as a byproduct of heroic altruism.

So, yes, there is a public obligation being trampled here. With power, comes responsibility, and since we have long had the power to prevent measles, we have the responsibility to use it judiciously.

I know, of course, that many who opt out of vaccines think they are being judicious, invoking everything from vaccine ineffectiveness, to vaccine risks, to the nefarious shadow-world of evil science run amok, to government conspiracies extending all the way to genocide. Most of this is absolute nonsense, and all of it is wrong.

No vaccine is perfectly effective, and all vaccines carry some, small risk. But there is, of course, some tiny risk attached to the use of baby car seats, and seat belts, too. There is some highly unlikely scenario, a one-in-10-million kind of crash, where being loose would work out better than being strapped in. Unfortunately, without a crystal ball, we can't predict such scenarios.

But whatever the actual numbers, we know quite reliably that car seats and seat belts save lives, a lot of lives. The reason to use them is not because they are 100-percent effective (they are not), nor because they are completely devoid of any possible or actual risk (nothing is), but because the net benefit to us all, and the probability of benefit to each of us, is astronomically in their favor. It's no contest.

The same is true of the vaccines long-since codified into our standard protocols, on which list the measles vaccine is an archetype. Immunization against measles is extremely safe. The vaccine is monumentally effective, as indicated by the near banishment of measles from the U.S. until the anti-vaccine movement invited it back.

This matters more than you realize, because we learn to forget to fear diseases we haven't had to deal with for a while. Roughly 30% of those infected with measles develop complications, some of which are life threatening. As recently as 2013, measles killed almost 150,000 children around the globe, in places where the vaccine is not readily available. In 1980, before the vaccine was in wide use, measles killed over 2.5 million people every year. If you think measles is a minor menace, it's only because you and I are privileged to live in an era that makes it so; an era of routine immunization.

I am, of course, aware of the anti-vaccine sentiment and arguments that are probably the root cause of the current outbreak, and potentially far worse to come. I can even appreciate the wince factor associated with getting an injection and taking a chance, while feeling fine. But the simple reality is that the conspiracy theories and paranoia are just noisy nonsense, and the notion that Nature taking its course is our best defense is a delusional load of New-Age revisionism. I have addressed the particulars before, and refer you there rather than reiterating them all here.

I know: I should tell you what I really think.

But honestly, we have enough troubles with infections we aren't yet able to prevent or treat. We have enough troubles with bacteria increasingly resistant to our antibiotics. We have enough troubles with a growing, global burden of chronic diseases. I do not want my grandchildren to grow up in a world where all such perils are compounded by the threat of dangerous infections we are fully capable of eradicating, but choose to invite back instead.

Measles is serious; we have forgotten because, and only because, the effectiveness of the vaccine has allowed us to forget. When measles was killing more than 2 million people a year, no one had the opportunity to forget what a bad actor it is.

Measles is preventable to an extent that offers us the promise of eradicating it altogether. But only by, quite literally, rolling up our sleeves, and getting it done. Immunization is one of the great achievements in medical history, eradicating smallpox, and banishing polio from much of the globe. Immunizations are neglected at our peril.

We have an unnecessary epidemic radiating out from its origins in the Magic Kingdom. It tells us that what happens anywhere is relevant everywhere, because it is a small world, after all. And it tells us there is no magic, in any kingdom, to substitute for what modern medicine can do.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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