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Saturday, February 21, 2015

Chronic obstructive pulmonary disease (COPD) exacerbations and respiratory syncitial virus--maybe a huge problem?

We're having a curtailed winter and early spring here in the inland northwest, or so it seems. We could still get a snowstorm or two, but the crocuses are blooming and the redwing blackbirds are singing by the unfrozen ponds. Despite the mild temperatures and sunny skies we are still having an influenza epidemic and many of our patients with chronic lung disease are becoming sick with wheezing and low oxygen levels. We have rapid tests for influenza and for another lung infection, respiratory syncitial virus (RSV) and I am presently seeing less flu and more RSV.

I have never routinely checked my patients with asthma and COPD exacerbations for respiratory syncitial virus. I thought that it was one of  those tests that would take so long to come back from the lab that the patient would be well before I ever found out the result. It is possible, though, to get a result back from a rapid antigen detection test (much like a home pregnancy test) using a sample of mucus from the back of the nose, in 30 minutes.

Last week two patients with severe wheezing and uncontrollable cough who were in the hospital with worsening of their COPD tested positive for RSV. Yesterday another one did. It is RSV season. In fact, it is even more RSV season than it is flu season. We are smack dab in the middle of RSV season which stretches from January to April. RSV is best known as the virus that causes acute lung disease in infants and children. In the US alone, over 80,000 children are hospitalized each year due to this virus and worldwide it kills more children under the age of 1 than any other infectious agent with the exception of malaria. More high risk adults, such as those with lung disease or immune suppressing diseases, contract RSV than they do the flu.

RSV is, for most of us, just a cold. It causes a stuffy runny nose and a cough, sometimes a fever. In small children or people with lung disease it can cause respiratory failure. It is very contagious. It is most often contracted by directly touching an infected person or objects with infectious secretions, even when they are dry. It is very important to avoid transmitting it in the hospital, and since we don't routinely test adults for it, we are probably very efficiently spreading it from infected to uninfected patients. The time from exposure to symptoms is 2-5 days. There is no vaccine, and people who get RSV can get it again, even during the same season, though perhaps more mildly. In very susceptible babies, a monoclonal antibody, Palivizumab, can be given monthly to prevent disease, but it is terribly expensive. For a baby it might run $1000 to $3000 per dose, but since it is dosed by weight, it would probably cost around $30,000 per dose for the average size adult. Not an option.

Prevention involves good hygiene, avoiding exposure to infected people, handwashing, and avoiding cigarette smoke which can make a person more susceptible. There is an antiviral medication, ribavirin, which is  active against RSV and sometimes used, primarily for immune suppressed patients like those with bone marrow transplants. Ribavirin costs about $30 a pill, would be dosed twice daily, has a black box warning for causing hemolytic anemia. It is not known if its use improves symptoms.

I think that it is likely that many of the winter adult lung disease admissions that I see are related to RSV. It is much more common than I believed. Since there are no really useful pharmaceuticals to treat it, none of the economic forces that lead to mass education are at work to raise awareness of its importance in the aging and chronically ill population that we internists see in the office or hospital. There is talk of vaccine development, but if natural infection does not give long term protection, it is unlikely that a vaccine will. It would certainly be nice if we knew whether ribavirin helped improve symptoms. Old fashioned and low tech prevention is probably the key to reducing its impact. I certainly need to be checking for it more often and thinking about taking precautions to avoid spreading it in the hospital or waiting room!

Tuesday, February 17, 2015

Nursing homes: what are we paying for and what are the alternatives?

The US population is getting older. There are about 9 million Americans who are over the age of 80 and about half of them need some kind of help in the activities of daily life. About 1.3 million Americans live in nursing homes. The average yearly cost to live in a nursing home is over $80,000, but that varies hugely by location. In San Francisco, the average cost of a year's stay is $144,000. In my state, which is notoriously cheap, if you live in a small town away from the big universities and population centers, it would cost closer to $68,000. This is quite the deal, but still more than double the average yearly salary for a working person. The total costs associated with nursing homes and assisted living in the US was $255.8 billion in 2013, according to the Medicare data.

Expensive, and...
What do you get for all that money? It varies, but generally nursing homes are older buildings and rooms are shared and often cramped. There is a hospital bed for each patient, sometimes a mattress on the floor if the patient is at risk of falling out of bed due to being demented and wakeful at night. That sounds a little barbaric, but it is actually a great idea when compared to bed rails or pads on the ground next to the bed, which can just make things worse. There is usually a shared private bathroom, with toilet and sink, sometimes a shower. There are 3 meals a day and snacks, like ice cream or pudding. There is a registered nurse available around the clock, but he or she may be responsible for 50 patients or more. There are licensed practical nurses available as well, and the ratio is a bit better for them, maybe 1 per 5 patients. There are nurses aids, less well trained, who help with dressing and toileting and cleaning up messes, and are spread pretty thinly. For-profit nursing homes, which make up the majority, have worse staffing ratios than state or non-profit facilities, and better staffing ratios correlate with better care and outcomes. There is often physical therapy available in a nursing home to help patients walk better or have less pain or regain function after an injury. Some nursing homes have speech therapy specialists who help improve swallowing and help patient learn to communicate after strokes. There are often activity directors who devise ways to make the time pass more pleasantly with games or crafts or music or movies.

People often end up in nursing homes when their health takes a sudden downturn, such as after an illness or injury that leads to hospitalization. After an acute illness older people are often profoundly weak and have lost the self confidence to return to their homes. Injuries such as fractures of the leg or hip may require that a person not bear weight, leaving them stuck in a wheelchair, needing help to get to meals or the bathroom. Many of these problems are temporary, but sometimes they are part of a cascade of events leading to no longer being able to function independently. When patients no longer require hospitalization, they may be transferred to a nursing home or "skilled nursing facility" (SNF or "sniff," for short.)

You can't always get what you want...
My patients tell me that nursing homes are, in general, terrible. Some patients are grateful and satisfied but most really dislike living in nursing homes. A large proportion of residents can't express themselves well enough to have an opinion that can be heard. What the ones who talk about it say is:

1. The food is bad. Usually it is mass produced and bland. In any case, people like their own special ways of making food, and this can't happen in an institutional kitchen.

2. It takes a really long time for a nurse or aid to come when a resident needs them. If this is to use the potty, often they are wet or soiled by the time help arrives, then they feel sorry and embarrassed. I think there is such shame attached to this that I only hear about a tiny fraction of it. If the problem is pain, the resident is often in such a state when the relief arrives that medicines don't work as well and they become irritable, alienating staff.

3. Mistakes are made. One of my patients, who was labeled a trouble maker, told me that 30% of the time he received his medications, there was some kind of error. Not necessarily large, but stuff like forgetting the aspirin, or giving him a whole rather than a half pill of something. The vast majority of mistakes like this would go completely unrecognized, not even showing up as a cause of morbidity, since most nursing home residents don't check to make sure their medications are correct.

4. Other residents are loud or rude or are just so sick that being near them is demoralizing. It would be nice if we could all be compassionate to our less fortunate or less polite peers, but many people need refuge, especially when they are old and vulnerable.

Like being in a sub-optimal summer camp as a child, people usually do adjust to living in a nursing home, but a large proportion of them, when they have returned home, tell me that they do not want to go back.

How about DIY?
It seems crazy that it should cost so much to live like this, when many nursing home residents were able to survive on a tiny social security check before they were admitted. What if they just arranged for the important part of this care without going to an actual nursing home? It sounds like a great idea, but the math doesn't work out that well. The average nursing home cost of $80,000 a year is what we have to beat. If we just start with the 24 hour care, it costs over $80,000 to pay someone $9.50 an hour for 24 hours a day, 365 days a year, and that isn't even a living wage. Compared to this cost, stuff like rent and food barely need mentioning, but $1000 a month for rent and utilities plus $400 a month for penny pinching groceries adds about another $17,000. Sharing the expense with a spouse starts to be comparable to the cost of a nursing home, but reliable home help that will not call in sick or smoke or mismanage money is extremely hard to come by. 

People have, for years, come up with creative ways of dealing with the process of aging. Before going further, I should mention the fact that humans have devised state and federal programs, Medicaid and Medicare, to help pay nursing home costs, since few seniors have enough money to pay their own nursing home costs. Medicare pays a large proportion of nursing home costs for patients who are expected to return home, but need a relatively brief nursing home stay after a hospitalization in order to do so. Medicaid will pick up the bill for nursing home costs when a senior can prove that they no longer have the resources to pay their own way. But there are also non-nursing home options that many people make work.

Living with family
As long as humans have existed, old people were taken care of by their extended families. This is shockingly inexpensive, since the very old don't eat much and already have all the clothes they need and rarely have expensive hobbies. Unfortunately not everyone has an extended family, and American lifestyles are not focused on having someone with time on their hands hanging out at home all the time. Even when family is available, things can go very wrong. About a year ago I saw a pair of sisters, one 96 and the other 102, who lived with their son in an apartment. They were hungry, thin and dirty and, according to the emergency medical crew, slept on a mattress together without sheets and just a grubby blanket. Their son wasn't cruel or abusive, just not much of a homemaker. There was shock and outrage among our hospital staff, but the sisters eventually went home with him because that was what they wanted.

On the very much more jolly end of the spectrum, one of my patients took her mother out of a perfectly fine nursing home to where she had prepared a room at her monastery. Her mother became more active and always had a novice assigned to her, who learned compassion by practicing it. She ate healthy food and complained about it, but she had complained worse about the nursing home. She got healthier and needed less medication. She eventually succumbed to old age, with hospice attending her at the monastery. 

Adult Family Homes
Since staffing is the biggest cost associated with care of the very old or disabled, adult family homes have arisen so that the cost can be shared among several clients. These are large private homes that have 24 hour staff, some of whom live there, and care for several older adults. Some of these are great. Near my home, there is a family home care place run by a family from Kenya, and I've been told that they are wonderful. One of the great benefits of a place like this is that staff turnover can be quite low. If staff live in the home or are close friends of the owners, they really get to know the residents and they get good at what they do. Also there are a smaller number of clients to take care of than in nursing homes, which means that care is more personal. Some of these places have come into the spotlight for providing terrible care, which is made more possible by there being less regulatory oversight.

Foster care
Adult foster care homes usually have one or very few clients, and caregivers need to have the basic knowledge necessary to care for their clients, but don't need to be nurses. If the chemistry is right, these can be great. I don't know of a clearinghouse for foster care providers, and in my experience these arrangements tend to happen when somebody knows somebody who is willing and able to do it.

Just a little bit of help at home
For people who don't need 24 hour care, staying at home and having help come in is much more affordable. Medicaid will even pay for this, in some cases. Some people remodel to make room for a roommate  and can trade rent for care duties. The patients of mine who have done this often have a long lasting solution that also can solve the problem of being isolated. They do, though, need to have contingency plans for vacations and illnesses and such. 

Out-sourcing--care tourism
What about out-sourcing? There are cultures that do personal care better than we do in the US, and at a much lower cost. Thailand, for instance. The last time I was in Thailand, there were professional massage places everywhere, and they cost maybe 5 or 10 dollars. Service in hotels was amazing and the staff actually seemed to enjoy doing their jobs well. The food was delicious. As it turns out, there are at least 2 nursing homes in Chiang Mai which are geared toward clients from Europe and the US. The very old in Thailand, and there are increasing numbers of them, are almost always cared for by their families, though there are a some facilities that cater to Thai seniors.  One of the ex-pat focused nursing homes is called The Care Resort and is pretty high end, with multiple levels of care and big beautiful grounds and outings to see elephants, or so it appears on the website. I can't find anything about cost on the website, but an article about it in the UK Daily Mail says that a year's cost is about 21,000 British pounds, which is about $35,000. Another such nursing home, which appeared on the website actually to have some Thai clients, is at the McKean Rehabilitation Hospital, which was a home and hospital for lepers when I spent time there in the 1980's, after finishing my residency. It was a beautiful place then, a bit outside of the city, with shade trees and open wards and a wonderfully creative approach to all aspects of leprosy as a chronic disease, but not a death sentence. The staff was cheerful and caring and there was an affiliation with the Presbyterian Church. The website makes it look fine, but not opulent. No prices are mentioned. The extended grounds still house some aging patients with leprosy (a disease which, despite its reputation, is not very contagious) who have no other home, and there is a strong outreach program to serve and rehabilitate people with all sorts of disabilities. 

Going to Thailand in one's great old age would have various benefits, not least of them elephants and tropical fruit. It is never cold, which would be good for those waning years when it is hard to get warm. There is a cultural kindness. On the not so bright side, though, family and friends would hardly ever visit. Medicare and Medicaid would not pick up the bill. Emergency hospital services would not compare favorably to the US. The recent movie, the Best Exotic Marigold Hotel, tells the story of some aging British people who move to India to live at a place that is trying to figure out how to provide assisted living for seniors, and portrays some of the drawbacks and benefits of outsourcing elder care. Moving to Asia is probably impractical for most aging Americans. Relocating would take a very committed friend or family member and a physically pretty intact potential nursing home resident and a hefty dose of courage and flexibility. 

Retirement Communities
Some people are wealthy enough and forward thinking enough to become part of continuing care retirement communities. For a chunk of money, which can range from $100,000 to over a million dollars, it is possible to have an independent house or duplex with the option to move into assisted living or a nursing home on the same grounds as the need arises. High end places of this type probably offer better staffing ratios and probably lower staff turnover than standard nursing homes, and it is certainly easier on couples who can live in close proximity even when one of the pair needs more help than the other.

Co-housing solutions
Cooperatives and co-housing offer another alternative to the corporate approach to aging care. This requires immense planning by community members, but is a way to deliberately and intentionally create an extended family with whom we can age.  

Having the conversation
So what should we do about the fact that we will all, with any luck, grow old? In the year 2050 it is estimated that 1 in 10 people will be over the age of 80. Perhaps half of them will require care of various levels of intensity. I will be 89 years old, if I'm not dead. The majority of people reading this will be 80 or older, or, possibly, dead. I venture to say that none of us wants to be in a nursing home. Are we really doing the hard work of remaining healthy and alive only for the opportunity to spend a small fortune living in a small fusty room with a roommate who may or may not be a suitable companion, waiting for a nurse's aid to come help us? Some solutions may involve technology, unloading overworked personal care givers by having robotic solutions to bedpans and med passing. Perhaps technology will unload everyone's job, and personal care will be one of the only jobs that still requires the work of a human. 

I think that it is mostly important for a conversation to begin, involving not just seniors who are vulnerable if they complain, but all of us who dread dependence and institutionalization. Those of us not yet old need to recognize that it is very unlikely that we will die before this issue becomes relevant. It is very inconvenient to say that the nursing homes we have now are an unacceptable solution to the problem of growing old. If we say that, we have to actually do something, because 1.3 million people need what nursing homes supply, and most of us are unwilling or unable to provide those services ourselves. 

Staying strong and useful
Besides actually planning for our years of dependency, perhaps we not-quite-yet-old also need to think about policies that make us less dependent. Most people dream of retirement, but the reality of not being useful or needed does not usually make us happy. I came upon a link to Thailand's initiatives on the elderly while looking at the nursing home situation there. In 2003 they passed The Elderly Act which, in addition to guaranteeing healthcare and basic food and shelter needs to older citizens, also grants them vocational training and support to become involved in community networks. I don't think we are doing that in the US. It might be a really good idea.

Monday, February 2, 2015

Vaccinations, measles outbreak and reasonable and civil discourse

Lately there has been an outbreak of measles, a vaccine preventable disease, along with an outbreak of people yelling at each other. There have been angry exchanges between people who would like all children vaccinated according to the recommended guidelines and people who support the rights of parents to choose which vaccines to give their children, if any, and when to give them. There has been much focus on the assertion, particularly, that the Measles/Mumps/Rubella vaccination (MMR) might cause autism. There is no believable evidence to support that assertion, but the questions of whether vaccination is safe and whether it should be required are much more interesting.

Yay Vaccines!
I am a big fan of vaccination as a means of fighting disease. It is an ingenious concept. The recipient of a vaccination gets an injection or oral dose of a weakened virus or bacterium or an inactive part of one, which causes the body's own immune system to produce cells that will recognize and kill the real virus or bacterium if it enters the body at some future date. Vaccinations are so much more elegant than antibiotics, which are chemicals that are broadly active against a whole bunch of different agents and only last until the body inactivates or excretes them. Vaccines stimulate the body's own very complex and amazingly effective systems for fighting infection in much the same way that natural infections or exposures would. These systems are then available to prevent disease whenever the need arises.

Herd immunity--that's how vaccines eradicate diseases
Vaccines are ingenious at the individual level, but they are even more ingenious on the level of populations. A vaccine raises an individual's resistance to a disease, but each individual is still somewhat vulnerable to that disease because the body's defenses are not absolute. Some vaccines are more effective than others, and some people have a more robust response than others. Infectious diseases persist in our communities because they move from one person to another. If the vast majority of people in the community are immune to a disease, as can be achieved with vaccination, the disease cannot be transmitted and will die out. The few people in the population who are not immune are protected by the many who are since the likelihood of coming into contact with someone with an active infection in such a community is very low. This effect is known as "herd immunity" and is one of the primary reasons that we should care about whether other people get vaccinated.

Curing smallpox
The word "vaccination" comes from the word root for cow, since the first vaccine in common use was derived from cows to fight smallpox. It had been observed that dairy maids who were infected with cowpox, a pustular disease, from touching the udders of infected cows did not get smallpox. In 1796 the physician Edward Jenner created a vaccine from that virus which became widely used. In 1979 smallpox, which killed as many as 500 million people in the 20th century alone, was declared eradicated. The vaccine was mandatory for school children, and I'm pretty sure I got it when I was a kid. It usually left a little scar on the upper arm but otherwise only rarely had side effects. Once in awhile, when a child had something that predisposed him or her to more serious infections, the vaccination would cause an overall body pustular rash which was very nasty. The vaccine is no longer in common use, but still exists, especially for preventing the tropical disease monkeypox which is similar to smallpox but milder.

Goodbye, polio
Other vaccine successes include polio, which was a virus that primarily infected children via the fecal-oral route, and caused paralysis, which was often fatal or disabling for life. The first vaccine was produced by Dr. Jonas Salk and was an injectable dead virus, and the second, close on its heels, was an oral vaccine that was a live attenuated virus (meaning it resembled the active virus but didn't cause polio.) Polio has been wiped out in most developed countries now due to vaccination, though it still breaks out in countries where vaccination is less common.

Measles, mumps and rubella
The measles vaccine was first licensed in 1962 and improved in 1968. It was combined with vaccines against mumps and rubella to create the MMR in 1971. It is estimated that the vaccine, in its first 20 years, prevented 52 million cases of measles, 17,400 cases of mental retardation due to measles effects on the brain and 5200 deaths. Measles causes fever, runny eyes and nose, a cough, a typical spotty rash and sometimes sore throat and spots in the mouth. I saw a case in Africa in a very miserable infant who probably had measles related pneumonia and had a reasonable chance of dying of the disease. Globally, measles vaccination has had a staggering impact. In the year 2000 it is estimated that over 700,000 people died of measles, primarily children, making it the 5th leading cause of death in kids. With a UNICEF backed measles immunization strategy, measles infections and deaths were reduced by 74% by the year 2010. Africa and India are major measles hot spots. There is no specific treatment for measles, so the only thing physicians can do is support the patient with fluids or oxygen if necessary and try to make sure the disease doesn't spread to others who might be vulnerable. Measles is very contagious. The vaccine, however, is very effective in preventing the disease. Rubella is another spots and fever disease, and can cause serious birth defects if a pregnant mother is infected with it. I had that one when I was a wee child and it didn't seem too bad, but I hope I didn't infect any pregnant people. There was no commonly available vaccine at that time. Mumps is a virus that causes swelling of the lymph nodes and can infect a young man's testicles, sometimes resulting in infertility. The vaccine is quite effective in preventing it, but not nearly as good for mumps as it is for measles.

Autism connection? Nope.
MMR is the vaccine at the center of the present controversy. In 1998 Andrew Wakefield, a gastroenterologist in England, reported 8 cases of children who developed autistic symptoms and gastrointestinal symptoms within 1 month of receiving the MMR vaccine. He proposed that the vaccine was causative, despite the fact that there was no obvious reason why it should be and there was no increase in cases of autism in the period after the MMR vaccine was introduced in England. His data was later questioned and thought to be fraudulent and the paper was retracted. Many studies have been done since then and have not shown any believable evidence that MMR causes autism, yet there are many people who still believe the vaccine/autism connection. Autism does present in early life and vaccines are given in early life, so a reasonable parent with a child who develops autism might suspect that the vaccine caused the autism, even though it did not.

But wait...not necessarily all good
Although it seems pretty clear that MMR doesn't cause autism, vaccines are not all benign and there are many diverse vaccines in common use. In the first 18 months of life the Centers for Disease Control recommends that a child receive about 24 immunizations, if I am reading this chart correctly. If successful, the vaccinations might prevent pneumonia, hepatitis, meningitis, chickenpox and the shingles that can follow in later years, tetanus, which can be fatal, whooping cough, most ear infections and rotavirus gastroenteritis. Also, of course, measles, mumps and rubella. But this is a lot of shots. Each one might cause muscle aches, listlessness and injection site redness and swelling. Children also often cry really hard and want never to go back to the doctor's office. The shot that prevents whooping cough can occasionally cause high fever and seizures and sometimes, though rarely, results in a temporary floppy unresponsive state that can't be a good thing. The reformulated version of this, which has been available for decades now, is less likely to cause these side effects, but the reactions still occur. The rubella part of the MMR can cause chronic arthritis in adults who are rubella immune if they receive MMR to boost their measles immunity.

Other vaccine greats
There are also immunizations for older children and adults which are just as miraculous and just as much of a concern with regard to side effects. These are recommended for various subgroups and situations, but not required for school aged children.  This is a list of all of the vaccines available in the US. One of my favorites on this list is the chickenpox vaccination. I must have been an odd and solitary child because I never got chickenpox. My twin got it when she was in her 20s and was really sick. She still has scars from it. Chickenpox is usually an annoying skin rash, with lots of small blisters that scab after a few days, but those little blisters can occur in the mouth and esophagus which makes eating and swallowing very difficult, and the virus can cause severe pneumonia. When I was in my thirties they released the chickenpox vaccine and I got one. Since that time I have been exposed to chickenpox, which is incredibly contagious, many times without getting the disease. This means that I, and the generation of children that have gotten that vaccine will never get shingles, which is a reactivation of chickenpox which causes pain and skin lesions, sometimes with lifelong pain and scarring. Despite the fact that the flu shot is sometimes disappointingly ineffective, I happily submit to it yearly because the flu is such a nasty disease and vaccination lowers my risk of getting it or makes it less severe if I do. The human papillomavirus (HPV) vaccination is also a winner. It is indicated in girls and boys to prevent genital warts that can cause cervical and penile cancer. It is still expensive and hasn't been embraced universally yet, partly because genital warts can also be prevented by having only one sexual partner for life and making sure that he or she has never had sexual contact with anyone else. Some parents forego the vaccine for their children because they believe that this will be achievable.  Cervical cancer kills 4000 women yearly and results in fertility threatening surgery and treatments in many more. The HPV vaccine could prevent these outcomes and potentially also make the dreaded pap smear obsolete.

Yellow fever: not without its problems
The yellow fever vaccine is both wonderful and terrible. In the 1600's yellow fever came from Africa to the Americas and eventually to Europe with captured African slaves. Yellow fever is so named because it causes liver failure with jaundice. It also causes nausea, vomiting, kidney failure and diffuse bleeding. It killed more soldiers in the Spanish American war than battle injuries. It slowed work on the Panama canal and infected people in Boston and other US port cities. In the early 1900's it was found to be caused by the bite of the Aedis aegypti mosquito and mosquito control led to significantly better control of the disease. It was still a considerable problem in places where mosquitoes could not be controlled so a vaccine was created in 1930 which has been very effective in reducing disease. Travelers to parts of South America and Africa are still at risk, as are residents. Unfortunately the vaccine can rarely cause a version of yellow fever in some people and can cause a fatal inflammation of the brain. The newer version of the vaccine is less likely to cause these side effects, but they can still occur. Despite the known side effects, travelers to many countries need to provide proof of vaccination in order to enter if they are arriving from an area with known risk of yellow fever.

The Swine Flu debacle
In 1976 there was an outbreak of swine flu (H1N1 influenza) in Fort Dix, New Jersey. One army recruit died, and there was fear that this virus, which was similar to the one that caused the influenza pandemic in 1918, would spread across the country. In fact, the only infections were at Fort Dix and 40 million Americans were vaccinated against it, resulting in quite a number of cases of Guillain Barre syndrome, an immune mediated paralysis that can result from both infections and vaccinations. On the bright side, apparently immunity from that vaccine did last until the most recent pandemic in 2009, so the folks who got that vaccine were less likely to come down with our most recent H1N1.

Where do we stand, legally?
The laws about vaccinating children differ by state. All states require some vaccinations in order to attend school, but some states offer exemptions, not just on the basis of medical issues such as immune system diseases, but on the basis of parents' religious or philosophical beliefs or values. With the recent measles outbreak, children who did not receive measles vaccination are being kept out of school, and some schools in California have reported up to 65% of students not being fully vaccinated due to their parent's objections. Some suggest more stringent requirements for vaccination, eliminating exemptions on the basis of religious or philosophical beliefs. West Virginia has already taken this step and several other states have only medical and religious exemptions.

Stupid people? Not so fast...
So are "anti-vaxxers" stupid and selfish? I don't think so. At least not necessarily more so than anyone else. Some of their concerns are not really valid, like worrying about the presence of tiny amounts of mercury as a preservative in some vaccines (hardly any now) and the possibility that multiple vaccines given at the same time will overwhelm the immune system (it's actually built for that: picture what happens when a child eats a handful of dirt.) There are some reasonable arguments against vaccinating ones children, even though I may not agree with them. Since vaccination protects the population and because it can be a big money maker for clinics, pharmacies and drug companies, it would not be surprising if we didn't hear much about occasional side effects. So suspicion is not entirely unwarranted. As a loving parent it is hard to be a party to 24 immunizations before the age of 18 months, especially since most of them involve sticking a needle into tender baby flesh. When a disease, like measles, seems to be vanishingly rare, how wise is it to expose one's children to an immunization which definitely has associated side effects (though not autism)? Some of the parents who reasoned in this way now have children with measles and many more have children who aren't able to attend school because they are not vaccinated. Are they selfish? They probably didn't think they were, but the vaccine isn't 100% effective and it isn't given until after a child's first birthday, so infection with measles does put other children, especially babies, at risk of measles and its complications.

Civil discourse--perhaps we should give it a try
How do we, as a society, want to deal with this issue? Americans are fiercely individualistic compared to many other countries, and we usually tell the government that they have no jurisdiction when it comes to our personal decisions. We draw the line (but it's a very wiggly one) at personal decisions that put our children or other people at risk. That's how our rules about vaccination came about in the first place. We, as physicians and nurses, now tell people about side effects of vaccines at the time they are administered, but we don't, in fact, allow them to refuse them for their children unless they also want to opt out of public school, except in the case of religious or philosophical beliefs. Do we want to close those loopholes as well? What we really ought to do is have civil and respectful conversations. We should carefully weigh both the value of controlling vaccine preventable and otherwise untreatable diseases against the actual observed side effects of vaccines. We want to support scrutiny by organizations that have as little vested interest as possible, such as the CDC. We want both sides, vaxxers and anti-vaxxers to avoid black and white thinking.