1/23/2015

Too rich to get sick? Disneyland measles outbreak reflects anti-vaccination trend


measles vaccine mmr
The measles vaccination is believed to be 99% effective at preventing the disease. A fall in vaccination rates has contributed to a two-decade high in measles cases in the US. Photograph: Joe Raedle/Getty Images
Travel north to south in Orange County, a coastal strip of 34 cities in southern California which includes Disneyland, and the growing size and opulence of the houses show people getting richer.
Trawl medical records, and you notice something else: children getting fewer vaccinations.
“The rate of immunisation falls as you go north to south. It tracks the socio-economic statistics in the county,” said Matt Zahn, medical director of Epidemiology and Assessment for the Orange County Health Care Agency.
At Capistrano Unified school district, for instance, there was a 9.5% rate of children not fully vaccinated because of parents’ beliefs. At the nearby, poorer Santa Ana Unified district, in contrast, only 0.2% of kindergartners had exemptions on file
A measles outbreak at Disneyland, stemming from an unvaccinated young woman dubbed patient zero, has shone a light on such dichotomies. Officials have confirmed at least 32 cases, almost all of them unvaccinated.
It is a strange first-world irony that wealthier, better-educated parents are the ones reducing infant vaccination rates, said Zahn. “Many people in this country have never seen a case of measles,” he said. “We’re a victim of our own success.”
The outbreak has triggered recrimination towards an eclectic group of activists who are accused of sabotaging immunisation campaigns by peddling medical myths. 
“If we get to a few thousand cases in this country we’ll start seeing deaths. That’s unconscionable,” said Paul Offit, chief of infectious diseases at Children’s Hospital of Philadelphia.
Patient zero became sick and contagious on 28 December, while at Disneyland. She flew to Snohomish County in Washington state for a few days, then returned to Orange County on 3 January. Health officials announced the outbreak on 7 January.
Her proximity to crowds at the theme park and airports and on planes helped spread the the extremely contagious virus: state health departments in Colorado, Utah and Washington have confirmed cases.
The Centers for Disease Control and Prevention (CDC) calls measles, a virus that lives in the nose and throat, the “most deadly of all childhood rash/fever illnesses”. About 90% of those who are not immune will become infected if they come close to an infected person, according to the CDC.
An estimated 20 million people worldwide contract measles each year. In the US, the CDC typically expects only 220 cases. Last year there were 644, a nearly two-decade high.
Measles vaccines are said to be 99% effective but anti-vaccine sentiment is growing in the US, especially in wealthy areas. In California more than 150 schools have exemption rates of 8% or higher for at least one vaccine. All are in areas with incomes averaging $94,500, nearly 60% higher than the county median, according to an Los Angeles Times study last year.
The virus’s relatively low prevalence in the US has emboldened parents to eliminate or delay children’s vaccinations, said Zahn, because they assume the risk of infection is negligible thanks to widespread vaccinations. “You’re riding on the immunisation rates in your community,” he said.
If enough parents do it, the system breaks down. But increasing numbers appear to be doing so over concerns about vaccine safety.
A debunked and withdrawn 1998 Lancet report linking vaccines to autism still lingers in some parents’ minds along with other worries, such as overloading a child’s immune system with multiple, simultaneous vaccinations – a concern lacking scientific basis, said Zahn. 
“It’s a grab-bag of issues,” he said.
High-profile opponents of existing protocols include the actor Jenny McCarthy, the non-profit National Vaccine Information Center and an Orange County doctor, Bob Sears, who is famous for authoring The Vaccine Book: Making the Right Decision for Your Child, which has sold hundreds of thousands of copies since 2007.
Sears declined an interview request for this article but directed the Guardian to a Facebook blog in which he played down the gravity of the latest outbreak, saying complications from measles were treatable and that the risk of fatalities in the US was close to zero.
Officials needlessly fanned anxiety about measles by giving “just the part of the truth that they want you to believe”, he wrote. “Don’t let anyone tell you you should live in fear of it. Let’s handle it calmly and without fear or blame.”
Offit, who battled a measles epidemic in Philadelphia in 1991, accused Sears of recklessness, ignorance and doing harm. 
“In an ideal world, which this is not, he would be censured by the Californian medical state licensing board, by a medical ethics board, by the American Academy of Pediatrics,” he said. “I find it unconscionable that a man in his position puts out incorrect information about measles.”
Offit assailed Sears in a 2009 article for the official journal of the American Academy of Pediatrics. 
Sears declined to respond to the accusations and pointed the Guardian to his published response to Offit. 
On Friday, the LA Times published an editorial and letters excoriating the anti-vaccine movement. 
“Ignorance cannot dictate public health,” wrote Richard Wulfsberg, a Studio City-based physician. “No unvaccinated child should be allowed to enter public school.”
Post Polio Litaff, Association A.C _APPLAC Mexico

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno

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A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left

Questions

1
What is that nature of the acute illness in infancy?
2
What is the nature of the subsequent deterioration?
3
What investigations should be performed?
4
What is the differential diagnosis of the cause of the progressive calf hypertrophy?

Answers

QUESTION 1

An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.

QUESTION 2

A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3

QUESTION 3

Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition

QUESTION 4

The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies

    Myositis

    Infiltration

  • tumours

  • amyloidosis

  • cysticercosis

    Link here