Maryn McKenna

Journalist and Author

"We Are Not Ready": Ebola Analysis from Front-Line Workers (And Bill Gates)

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A volunteer gets sprayed a bleach mixture while training for a mission to support the German Red Cross in Liberia, Oct. 23, 2014.

A volunteer gets sprayed a bleach mixture while training for a mission to support the German Red Cross in Liberia, Oct. 23, 2014. Markus Schreiber/AP

Bill Gates speaks at TED 2015 in Vancouver. (Image courtesy TED on Flickr (CC).)

Bill Gates speaks at TED 2015 in Vancouver. (Image courtesy TED on Flickr (CC).)

We’ve just passed a difficult and little-noticed anniversary: Last week, the Ebola epidemic in West Africa achieved its first birthday. Though the viral outbreak has been contained, it is still not under control: According to the World Health Organization, cases continue in Sierra Leone and are rising again in Guinea. Liberia was about to record an entire incubation period without a new case — a signal that the chain of person-to-person transmission might have been broken — but on Friday, it announced that it had found a single new case. How that woman became infected is unclear; it is possible that she represents, not a new outbreak, but a brief interruption in an otherwise promising trend.

It has been decades since there was an epidemic of this persistence and magnitude. No other Ebola outbreak matches it; nor does the 2003 epidemic of SARS. You would have to go back to the early days of HIV in the 1980s, or to the flu pandemics in 1968, 1957 or even 1918, to find an outbreak that sickened so many people, challenged international response capacity so much, and instilled such fear in other countries.

The anniversary has triggered reflections. Some criticize the response to Ebola for being inadequate and slow. Others — such as two talks at last week’s TED conference, one by Bill Gates — extract lessons that should inform responses to future epidemics.

Because there will be future epidemics. That’s for sure.

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Did Poor Vaccine Response Contribute to California's Whooping Cough Outbreak?

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Breaking news from the 51st ICAAC meeting in Chicago: Physicians from the Kaiser Permanente Medical Center in San Rafael, California say they have found an unexpected amount of pertussis — whooping cough — in pre-teen children who had received their mandatory school-entry vaccination booster at age 5 and should have been protected from the disease until about the time of their final childhood booster dose at age 12.

The physicians said case records suggest the vaccine may have protected children for less time than it was expected to. They speculate that the cases they recorded — along with additional cases that are likely to have occurred outside Kaiser’s  patient population — helped amplify California’s 9,000-person pertussis epidemic in 2010.

“The vast majority of these were fully-vaccinated children,” Dr. David Witt, the medical center’s chief of infectious diseases, said in a press briefing during the meeting. “That was the surprise.”

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What Vaccine Refusal Really Costs: Measles in Arizona

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Every once in a while, there’s news of a measles outbreak. On the surface, they don’t involve large numbers of cases — there’s one in Minneapolis right now that has racked up 21 cases so far — and so people seem to wonder why these outbreaks are such a big deal.

Here’s one reason why: Measles transmission within the US stopped in 2000 because of vaccination. Outbreaks here start with an importation from somewhere else where the disease still flourishes — but they gain a foothold because lack of vaccination, primarily from vaccine refusal, lets the disease get past what should be an impregnable barrier of herd immunity to attack those who are too young to be vaccinated or whose immunity has faded.

Here’s another reason: Stopping the measles virus before it can cause serious disease — and by “serious,” I mean deafness, pneumonia, encephalitis and miscarriage — is incredibly costly and labor-intensive. An account published overnight in the Journal of Infectious Diseases gives a glimpse at just how costly. To stop a 14-person outbreak that began with one unvaccinated tourist visiting a US emergency room, the Arizona Department of Health had to track down and interview 8,321 people; seven Tucson hospitals had to furlough staff members for a combined 15,120 work-hours; and two hospitals where patients were admitted spent $799,136 to contain the disease.

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Great reads: POX — a history of vaccine resistance

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A swiftly moving contagious disease threatens children. The government urges parents to vaccinate. But parents are suspicious: They believe the vaccine has unpredictable side-effects and they distrust the government’s motives. When persuasion fails, coercion takes its place. The government demands vaccination — and a showdown looms.

In many aspects, that vignette sounds like today, when pertussis and measles are spreading through unvaccinated children. But what it actually describes is a lost episode of history: not 2010, but 1900, when smallpox spread across the country and life-saving universal — and compulsory — vaccination was imposed on the US population.

In a new book, POX: An American History (The Penguin Press, $27.95) historian Michael Willrich describes what happened next.

I wrote a history of US public health, and so I thought I knew something about vaccines, but I had never heard this story. I asked Willrich, an associate professor at Brandeis University, to answer some questions about it.

Among all the vaccine-preventable diseases, smallpox was uniquely deadly — and so I always assumed there was wide agreement over eliminating it. But POX tells the story of a broad, and surprisingly little-known, resistance movement against smallpox vaccination. Tell us that history briefly. [Read more…]

Whooping cough: Back, with a vengeance

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A few years ago, I went to India on a reporting trip. When I came back, I had a troublesome cough. I figured I’d picked up a bronchitis aggravated by New Delhi’s smog-laden air, or by the dung smoke from the fires in the villages where I’d spent most of my time. The cough got worse instead of better. It was especially bad at night: I’d lie down to sleep and that would trigger a paroxysm. Sometimes I’d cough until I couldn’t breathe. A few times, I vomited. Eventually my side began to hurt. (Months later, I discovered I’d cracked a rib.)

As a medical reporter, I spent most of my time around doctors and nurses, but I had a rule about never bothering them — first because I was pretty healthy, and second because no one wants to be the guy at the cocktail party who finds out someone’s a doc and backs them into the corner of the buffet table. But one day, worn out by the spasms, I mentioned my symptoms to a friend. His eyes got big. He went and got a textbook.

I didn’t have bronchitis. I had pertussis — whooping cough.

This made no sense, of course. Between a day job as Scary Disease Girl and a childhood spent moving between continents, I am pretty much the most vaccinated person on the planet.  I’d had my full series of pertussis vaccinations as a child. Surely I was protected?

Actually, no — and unless you’ve had a booster, neither are you. The immunity created by the 5-dose childhood series wanes over time; by the age of 12, even fully vaccinated people are vulnerable to pertussis again. Since 2006, the Advisory Committee on Immunization Practices has been recommending a single additional pertussis (Tdap) booster for anyone between the ages of 11 and 64. That may seem like overkill — adult cases of pertussis in previously vaccinated people are often milder than the child version; after all, I survived my bout. But as with so many vaccines, the beneficiary here isn’t just the adult taking the booster. Even more, it’s the more vulnerable person to whom that adult might pass the disease: an elderly person with age-related immune decay; someone with a chronic disease; an infant too young to be vaccinated. In those people, the disease can and does kill — as it did an 18-day-old infant, Nelyn Baker, whom I wrote about in 2004.

Because vaccine immunity fades, pertussis is always with us: in good years, about 1,000 cases across the United States. Lately, though, we’re in bad years. Pertussis cases are rising dramatically, in Alabama, Georgia, Arkansas, Texas, South Carolina, Michigan, Oregon and Ohio. The worst by far is California, where so far this year almost 1,500 cases of pertussis have been reported and another 700 are suspected — compared to 258 for the same time period in 2009.

“We are facing what could be the worst year for pertussis that this state has seen in more than 50 years,” Dr. Gilberto Chávez of the California Department of Public Health said last week in a statement put out by the agency’s Center for Infectious Disease.

The worst news in this upsetting trend is this: We’re doing it to ourselves. As far as anyone can tell, the rise in pertussis is not due to any change in the organism, or to any mysterious error among the manufacturers who make pertussis vaccines. It’s due to vaccine refusal, to parents turning away from vaccines because they think the vaccines are more harmful than the diseases they prevent — or, more selfishly, because they think the wall of immunity created by other vaccinated children will protect their unimmunized ones.

That’s an incorrect assumption, by the way. Work published last year by several scientists at Kaiser Permanente of Colorado found that unvaccinated children were 23 times more likely to contract pertussis than vaccinated ones. (Glanz, McClure, Magid et al., Pediatrics 2009, doi:10.1542/peds.2008-2150.) And yet, as numerous stories (LA Times, MedPage Today) have pointed out, California’s epidemic has blossomed in a state that gives some of the most generous “personal belief exemptions” from vaccination — and the epidemic’s worst hot spots neatly correlate with the most concentrated areas of vaccine refusal.

Pertussis is an awful disease. A child in the throes of a paroxysm sounds like nothing else on earth. Children turn blue, give themselves black eyes, die. We kept it down to manageable levels with the help of a vaccine. That we would willingly bring it back it is beyond belief.

(For a physician’s take on pertussis, see this post by my fellow former Scibling Pal MD. The CDC’s information page on pertussis is here and the National Network on Immunization Information explains the vaccination schedule here. H/t to the infectious-disease mailing list ProMED for starting me thinking.)