Crozet Annals of Medicine: On Being More Judgmental

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By Robert C. Reiser, MD

Dr. Sudhir’s excellent article last month nicely highlighted the challenges to empathy that are ever present in the chaotic and unpredictable ER. Patients will indeed ignore the eminent doctor’s grand entrance while continuing to text or talk on their cell phones. I understand this; patients are busy and perhaps I have come at a bad time. I can always reschedule.

Fortunately I have never seen anyone who is dying feel the need to text so I find such ostensibly rude behavior actually reassuring. I have enough to do sorting out the critically ill from the temporarily unwell and anything that makes that job easier is welcome.

Another thing that makes it easier for me to discover serious illness is not vaccinating your children. It is the rare physician who could miss the characteristic rash of measles, for example. I suppose it is possible, though; the majority of doctors in the current generation have never seen a case of measles (rubeola or red measles). This is because measles was eliminated in the U.S. in 2000 thanks to a highly effective vaccine. Case closed. I liked having one less serious illness to worry about.

And yet measles is back! Last year there were 644 cases in the U.S. The average has been about 60 cases per year for the last two decades, mostly cases imported by travelers from other countries where measles is still endemic.

The majority of last year’s cases, 382 of them, were in a community of unvaccinated Amish people in Ohio. The Amish are known as plain people. They tend to avoid technology like cars and telephones, but also vaccines.  The source of their outbreak of measles was an Amish missionary who had traveled (by plane, interestingly) to the Philippines and back. The Philippines has seen 60,000 cases of measles in a multi-year epidemic of measles. The wide world is full of measles to import home to the U.S.

The Amish missionary did see his doctor in Ohio when he fell ill, but was misdiagnosed as having dengue fever. Three hundred and eighty one patients later I bet every physician in that community is now up to speed on diagnosing measles. And virtually all of the Amish got vaccinated after seeing what measles looks like first hand.

What does measles look like? Fever up to 105 degrees with cough, coryza (runny nose) and conjunctivitis (pink eye)—the three C’s that herald the onset of the disease before the dramatic spotted rash spreads from the face to the torso and then to the limbs. Patients are contagious as much as four days before the characteristic rash shows up and for about four days afterward and, by the way, it is the most contagious disease in the world.

The virus is spread by respiratory droplets from person to person. The virus remains infectious in a room for two hours after an infected person has left the room. The transmission rate is an astonishing 90 percent among the unvaccinated. The overall mortality rate is 3 percent (lower in the U.S.) and the complication rate is about 30 percent. Complications include severe pneumonia and encephalitis (inflammation of the brain).

There is a vaccine, the MMR, given in two doses, that is 99 percent effective at preventing rubeola, but a surprising number of parents are choosing to not vaccinate their children. There are likely several reasons for this, but the most common reason is the belief that vaccines are not safe.  The most famous anti-vaccine advocate is Jenny McCarthy, a Playboy Playmate and reality show B-list actress. She believes that vaccines cause autism. No reputable medical authority supports that belief.

And so measles has roared back. Already in 2015, one month into the year, we have 98 cases spread out over 14 states, almost all of it in unvaccinated kids exposed at Disney Land in California. Most of the unvaccinated children’s parents are affluent and highly educated, the demographic most associated with the anti-vaccination movement.

While a healthy child may ultimately do well after contracting measles, he or she is risking spreading it to contacts who may be immuno-compromised by age (very old or very young), illness, or transplant patients, whose mortality can then be as high as 55 percent.

Here at home in Crozet we had a long hiatus from the measles. In fact until 2011 we went for twenty-one years without a single case of measles in the Thomas Jefferson Health District. Twenty-one years without a case of measles!

In 2011 we did have a small outbreak of measles in Crozet in unvaccinated children. A rigorous quarantine and vaccination campaign halted that outbreak but many kids missed the last two weeks of the school year.

Parents have to choose who to believe, Ms. McCarthy, 1993’s Playboy Playmate of the Year, attractive no doubt, but possessing no scientific training or background, or the Centers for Disease Control and Prevention, the World Health Organization, the AMA, the American Academy of Pediatrics, The American Red Cross, UNICEF, the Bill and Melinda Gates Foundation, and the National Institutes of Health, who all have declared vaccines crucial for the health and safety of our children and completely refuted the link between vaccines and autism.

But perhaps neither Jenny McCarthy nor the AMA holds much sway over the average parents. Perhaps we need to look to a more familiar advisor, someone like Roald Dahl, beloved children’s author (Charlie and the Chocolate Factory, The Fantastic Mr. Fox). Here is his open letter to parents regarding measles:

“Olivia, my eldest daughter, caught measles when she was seven years old. As the illness took its usual course I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of coloured pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.
‘Are you feeling all right?’ I asked her.

‘I feel all sleepy,’ she said.
In an hour, she was unconscious. In twelve hours she was dead.

The measles had turned into a terrible thing called measles encephalitis and there was nothing the doctors could do to save her. That was twenty-four years ago in 1962, but even now, if a child with measles happens to develop the same deadly reaction from measles as Olivia did, there would still be nothing the doctors could do to help her.
On the other hand, there is today something that parents can do to make sure that this sort of tragedy does not happen to a child of theirs. They can insist that their child is immunized against measles. I was unable to do that for Olivia in 1962 because in those days a reliable measles vaccine had not been discovered. Today a good and safe vaccine is available to every family and all you have to do is to ask your doctor to administer it.

Incidentally, I dedicated two of my books to Olivia, the first was James and the Giant Peach. That was when she was still alive. The second was The BFG, dedicated to her memory after she had died from measles. You will see her name at the beginning of each of these books. And I know how happy she would be if only she could know that her death had helped to save a good deal of illness and death among other children.”

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