Measles on my Mind by Guy Nicolette, MD

April 22, 2019

Measles on my Mind

Guy Nicolette, MD, CAQSM
Assistant Vice Chancellor, University Health Services
@AVCGuyNicolette

Measles is back in the news —  the latest outbreaks of note are in New York state.  With this recent spike in cases, the United States has now seen the highest yearly number of infections reported in 2019 than in over two decades (with the exception of 2014). And it is only April.

Measles is a highly contagious viral infection without specific antiviral treatment.  Most of the time, the infection is managed by the wonderful human immune system and no obvious sequelae persist.  But, like many viral infections, a small percentage of the time it can be very serious and even life-threatening. These higher-risk situations typically happen in the very young and those with a reduction in immune function. There does appear to be a higher risk for complications for those that contract measles after age 19. A wealth of information exists online including the CDC webpage on measles, and if you think you might have measles please seek medical attention promptly.

Measles was considered all but eradicated in the US a couple of decades ago, but that doesn’t mean that we won’t continue to see an increase in infections. As a nation we have two main considerations when addressing the resurgence of measles. The first is a continued increase in global travel.  Many areas of the world do not have the access to health care — and specifically measles vaccination — that we enjoy in the US. Travelers from these countries as well as unvaccinated travelers to these countries can become infected and transmit the infection once back in the US.  

The second factor is the choice to remain unvaccinated. That is what’s been on my mind.  I am a staunch supporter of individual rights and defaulting to a person’s right to choose in every reasonable way, including health care.  I don’t believe in mandatory medical treatments or preventive measures of any kind for an adult with the capacity to make such a choice. I’m not in favor of prosecuting parents of children who decide not to vaccinate for ‘child abuse’ or ‘willful neglect’.  However, I do think it is reasonable to have the discussion regarding this choice and whether we push harder for more evidence-based education regarding measles and other vaccinations, including ‘hard waiver’ approaches. We also have to be realistic given that no vaccination is absent any risk as adverse outcomes are a chance resulting from any choice, medical or not. Living in the world means a constant stream of risk vs reward decisions and 100% safety is simply not possible.  We all should do better discussing these known risks and strengthening our medical shared decision-making.

I dispute the myth of “anything natural is by definition good for us” (see: cyanide, arsenic, and so on).  To paraphrase Swiss alchemist Paracelsus, toxicity (“poison”) is all dose-related. I encourage you to learn about the chemical makeup of apricot and peach pits, cucumbers, and apples!  More to the point of vaccination, the corollary that anything “unnatural is toxic” is also flawed. Many of the individuals and groups that advocate abstinence from vaccination focus on the ‘unnatural’ way these vaccines work or on their ‘unnatural’ components.  Again, there is a dose-dependency for all chemicals. I would also point to any number of man-made inventions and conventions that have overwhelmingly been accepted as adding health benefit: probiotic capsules, the heating/cooking of certain foods, broccoli, artificial joints. Not to mention the antibiotics that have saved countless lives, prolonged our high-quality years of life, and diminish suffering when used judiciously.   I also believe that vaccinations fall into this category: the risk versus reward profile appears to be very heavily weighted on the reward side. Another issue is that certain vaccine-preventable infections have a higher incidence of harm than others, and that should be weighed when evaluating risk and reward of that particular vaccine.

This isn’t to say vaccines don’t carry some risk. They do. Certainly, medical clinicians also do bear some responsibility for any anti-vaccination trend as vaccination wasn’t always presented with full disclosure of some of the risks.  Pushback regarding this non-disclosure is reasonable. No matter how rare the risk, I believe a patient deserves to know potentially significant proven risk from any treatment to make an informed decision. There does seem to be a causal relationship of some vaccines to febrile illness and seizure activity, risks of neurologic malfunction (e.g. Guillain-Barre syndrome), deafness, coma and the CDC even lists death to name the most catastrophic complications. At the same time, I want to be clear that scientific review of current evidence shows no causal relationship between vaccination and autism.  My professional clinical approach, backed by evidence, is that for most vaccines the risk of the infection far outweighs the risk of the vaccination in a healthy person in normal circumstances.

Here at UC Berkeley (as at most US universities, especially public institutions), there is a vaccination requirement that, amongst others, includes measles immunization or proof of immunity.  University Health Services manages the compliance of this mandate. We take our public health responsibility very seriously, and want to encourage anyone on campus that does not have immunity to measles to strongly consider vaccination.  The odds of an outbreak here are lower given the high rate of vaccination among students, but an outbreak could still happen here and we are prepared for that.

Given the experience of measles outbreaks at other universities (and depending on the situation), we would consider the step of limiting those without documented proof of vaccination from accessing campus facilities.  This does lower the chance of those individuals from contracting measles, of course, but the main intent is not paternalistic. The more important reason is that it lowers potential spread to those unprotected individuals who have compromised immune functioning or couldn’t otherwise be vaccinated. In other words, it helps your fellow Berkeley student, staff and faculty.

In closing, I truly want everyone to be the healthiest person they can be and that just isn’t a ‘one-size-fits-all’ thing.  We all have different perspectives and experiences that lead us to approach health and wellness and care in unique and interesting ways.  However, data supports strongly that overall, vaccination has led to dramatic reductions in medical illness and in prolonged quality of life.  And I am proud that UC Berkeley University Health Services has the experience and capacity to help manage outbreaks with medical, emotional and epidemiologic support.  My goal is that we have zero vaccine-preventable outbreaks in our campus community, and I want to continue these discussions and honest debates whenever and wherever I can.