With reams of scientific data available online, and information available through the CDC, your personal physician, and other community forums, clearly you know all there is to know about vaccines, viruses, and epidemics...or do you?
With the recent measles outbreaks in Monsey, Brooklyn, and Lakewood, as well as in Europe and Israel, government leaders, school principals, and parents face difficult decisions – even though, as of November 18, 2018, there is no known outbreak of the measles virus in Baltimore.
Although vaccination has been proven to prevent and even eradicate many diseases – and although a majority of the population is vaccinated – a parallel movement has grown up of parents who believe that vaccination may harm their children and have refused to have them vaccinated. Feelings run high on both sides, as might be expected when issues of life-and-death, literally, are involved.
To understand more about the current virus outbreaks and vaccination in general, I turned to Dr. Robert Edelman M.D., a world-class expert on infectious diseases and vaccination who, remarkably enough, is part of our own Baltimore community.
Dr. Edelman has conducted vaccine research for more than 50 years. His career includes service with the U.S. Army Surgeon General’s Office in Washington D.C.; the Walter Reed Army Institute of Research laboratory in Thailand and Vietnam; the U.S. Army Medical Research Institute of Infectious Diseases at Fort Detrick, Maryland; the National Institute of Allergy and Infectious Diseases; and, for the past 30 years, the University of Maryland School of Medicine’s Center for Vaccine Development and Global Health (CVD-GH). He has served as an expert consultant on vaccines for the U.S. Department of Defense, the NIH, the World Health Organization, the Bill and Melinda Gates Foundation, and many pharmaceutical companies.
Dr. Edelman has conducted vaccine research to prevent many infections, such as influenza, malaria, dengue fever, anthrax, smallpox, and diarrheal diseases. At the CVD-GH, he helped to develop the recently-licensed cholera vaccine, the only cholera vaccine approved for use in U.S. travelers going abroad. He has won many awards for his research and teaching, and has published nearly 300 peer-reviewed scientific papers, abstracts, editorials, and textbook chapters.
In my conversation with Dr. Edelman, I was hoping to separate fact and fiction and cut through the hysteria and misinformation to create clarity, so that informed citizens can make the best decisions for themselves and their families, their institutions, and their communities.
Ira Friedman: Dr. Edelman, it has been over 200 years since the first vaccine, for smallpox, was tried in England. What is your opinion of how far vaccines have come?
Dr. Robert Edelman: I’ve been asked many times about my opinions on vaccines. I consider them to be one of the great gifts of the Almighty to the people of this world. The most important methods to prevent infectious diseases around the world include potable water, flush toilets, pasteurization of milk, and vaccines. These rank as the top preventive methods to prevent the large number of diseases in the 1800s and throughout the early 1900s. I am an unabashed proponent of using vaccines to help all populations. Though I’m semi-retired, I am still engaged in vaccine policy and research, and furthering vaccine benefits the world over.
IF: Many of us had measles, uneventfully, as children. What’s all this hysteria about?
DRE: Measles is an extraordinarily severe illness. It ranks second to smallpox in terms of fatal outcomes. Approximately one per 1,000 patients will die of measles. Maybe three per 100 patients will have to be sent to the hospital to be treated. Measles causes encephalitis, pneumonia, and severe diarrhea, which, together, are the main causes of death in childhood worldwide. As a matter of fact, there is an ongoing measles outbreak in Israel with over 1,300 active cases to date, and an 18-month-old child who was not vaccinated unfortunately died recently in Jerusalem. A rabbi in Safed and another Israeli child have been admitted to hospital intensive care units for life-threatening measles pneumonia. There is a rapid transmission of measles throughout Israel right now, particularly in the Orthodox community.
IF: Is it mostly people living in underdeveloped nations who are dying of viruses?
DRE: Yes, in underdeveloped countries there is less vaccination because they have no access to vaccines, and many of the people are malnourished and underfed, greatly affecting their general health. We do know that the Bill and Melinda Gates Foundation is active in many of these countries, desperately trying to get people vaccinated. So, being unvaccinated makes these persons more susceptible to these diseases. People die all the time from viruses, tens of thousands of deaths in some of those countries from measles. Common viruses, which we have eliminated in America, are still present in those underdeveloped countries. To give some numbers for clarity, three to four percent of those children will die from contracting measles, compared to approximately .01% of well-nourished children. There is no drug to treat measles once it’s contracted. They need access to a hospital with a pulmonary machine, where they will likely be intubated until they recover or die. Measles is a lethal virus with a very high virulence. A child or teenager may have to be quarantined for several weeks in an intensive care unit.
IF: Does the vaccine prevent measles?
DRE: I can tell an individual who is vaccinated, you can be at least 95% sure that you will not come down with measles. If you do come down with it, you will only suffer a mild illness compared to unvaccinated persons.
The first measles shot is typically given at 12 to 16 months of age. However, during times of measles outbreaks, you can give your child a shot as early as six months. The second shot is typically given between five and six years old. If you have a young child – six months or older, for example – who has not been vaccinated or had all his shots, you can give the child human immunoglobulin, which is safe serum collected from people who have anti-measles antibodies in their blood. These pre-formed antibodies against the measles virus will protect the child to approximately 85% or more.
It’s important to know your immunization status and make sure all your shots are up to date. I would urge all those in Israel and the U.S. who have not been vaccinated to do so immediately, no matter the age. Elderly persons are more severely affected by measles virus than children. It is vital for each and every individual to speak with or consult their personal M.D., and not rely on unknown vaccination policies spoken amongst friends, or others who may be misinformed.
IF: How is the measles virus spread?
DRE: The measles virus is highly infectious, because it can survive a long time in the open air. When someone with the infection coughs, sneezes, or talks, infected droplets are sprayed into the air. These infected particles are then inhaled by people nearby. If a measles-infected person walks into a room and coughs, and you have 10 people in the room, nine of those people may come down with measles by inhaling microscopic particles of infected saliva! It’s one of the most infectious viral diseases known to mankind. If you shake hands with an infected person and get their infected sputum on your hands, and then put your finger in your eye, nose, or mouth (which we habitually do), you will inoculate the virus onto these mucous surfaces.
By the way, you should know that measles and other respiratory infections can be transmitted by persons in airplanes. For example, if someone is coughing on an airplane, and you are sitting alongside or immediately in front or back of that person, you may be at risk to catch that person’s infection. But if you are sitting several seats further back, you likely wouldn’t, because the plane has a strong HEPA filter which continuously cleans the air in the cabin. It’s been said that if someone is coughing on an airplane near you, change your seat! We don’t know you’ll get infected but it could raise your chances. This has been clearly shown, albeit infrequently, for tuberculosis and influenza virus.
Illness begins 10 to 14 days after you have contacted the measles virus. The illness consists of a sore throat, cough, loss of appetite, fever, and a rash. Your eyes may get red, and you will get quite sick. The virus can settle into the lungs and cause pneumonia. Measles usually lasts one to two weeks, if uncomplicated by pneumonia or encephalitis.
IF: Who is susceptible to measles?
DRE: Individuals are only considered protected or immune to measles if they were born sometime before 1957 to 1963; if they have received two doses of the measles, mumps, rubella (MMR) vaccine; or if they have had measles confirmed by a healthcare provider. If you were naturally infected by wild measles virus before 1963, you will have 100 percent lifelong protection. By contrast, the vaccine provides 95 percent protection.
IF: If you were in Jerusalem, or anywhere in Israel now, how would address this outbreak?
DRE: If I were a doctor in Jerusalem right now, I would first advise patients to take all precautions necessary against contracting the virus, including frequent hand washing, avoidance of persons with fever, particularly those with respiratory symptoms and a rash, and immediate measles vaccination if they are unvaccinated or only partially immunized with one shot.
I was informed that measles has entered into the Mir Yeshiva in Jerusalem. A student there reported a roommate who came down with measles just after arriving from Switzerland. In fact, Europe is now being overrun by 70,000 cases of measles! The anti-vaccine crowd and the attitudes of people in Europe, by refusing vaccinations, are causing this upward spiral of cases.
We also have large numbers of unvaccinated people in areas of Brooklyn, Lakewood, and Monsey, where only 90 percent or fewer are vaccinated. We are striving to vaccinate 95 percent of eligible individuals to prevent further spread.
IF: Does a state have the authority to force persons to vaccinate against measles? Does the U.S. government mandate it?
DRE: As far as I am aware, a state or city can mandate that a child be vaccinated to prevent spread of the virus. A school or school board can mandate that vaccinations be administered for school attendance. For example, citing influenza and its risks, the New York City Board of Health ruled, in 2013, that all children from six months old to age five must get a flu shot each year, and their parents must show proof of that shot. The ruling was unanimously approved by the courts. The only exception I know of is if someone has a medical condition in which their immunity is suppressed or compromised or has an allergy to a component of the vaccine formulation, in this case giving them the vaccine could be dangerous to their health. Certain populations, such as J’s Witnesses, generally seek a religious exemption. By contrast, religious exemptions are inconsistent with Jewish law, and, with certain exceptions, with Islamic law.
IF: Do those who fear vaccinating have a basis for that fear?
DRE: Let me cite some historical examples: May 2018 marked the 222nd anniversary of Edward Jenner’s first experimental vaccination using cowpox to protect against smallpox. Jenner’s discovery, and its rapid adoption around the world, launched a medical revolution that continues to shape how to approach disease prevention. The popularization of smallpox inoculation during the 18th century was part of an Enlightenment culture that fostered scientific inquiry and the global circulation of knowledge.
Yet when the first smallpox vaccine came out in 1803, there was much pushback against it in England. People thought they would get smallpox from being given this shot. This was the beginning of the anti-vaccine movement. Anti-vaxxers have waxed and waned since then. But that movement received a big push from an article written in 1998 by a physician and published in the medical journal Lancet, in which he reported 12 cases of autism. He went on to write that their autism developed after being given a measles vaccine. This was met with a firestorm on the internet. Millions of people were exposed to his data.
This doctor’s research was subsequently proven fake. It turned out he was being paid by lawyers who were hoping to sue the vaccination company. Despite that revelation, the falsified information fomented fear and anxiety and resulted in many people losing confidence in not only the measles vaccines but in all vaccines, including pediatric vaccines, such as whooping cough, tetanus, diphtheria, polio, etc.
IF: Why do people continue to believe this false information?
DRE: Resulting from vaccine anxiety, anti-vaxxer websites and blogs flourished. People would share anecdotal stories of their child being vaccinated, followed by development of psychological and social disorders like autism. This is not to dispute that the child may have developed autism, but it is far from clear that it was due to the vaccine. There are millions of children who get vaccinated, so you are bound to see a temporal association between a vaccination and a biologically unrelated illness on occasion. I am only bringing up some of the reasons why these anti-vaxxers are so strong in their beliefs. They wouldn’t have been so strong if we didn’t have the internet to add flame to the fire. The internet is the main conduit for the idea. The media has also spread anti-vaxxer attitudes on occasion. The internet allows for people’s opinions, whether false or true, to be verified by others who themselves may not have factual information. Also spawned on the internet and since disproved is that thimerosal mercury preservative causes autism, that too many vaccines given too soon causes autism, and that personal anecdotes trump scientific study of thousands of vaccinated persons.
IF: What would you say to the anti-vaxxers?
DRE: I am not saying something shocking when I say that we live in a risk-and-reward world. The odds are in your favor of it not being fatal should you get vaccinated; whereas if you remain unvaccinated, you take a risk which can be fatal. You may have heard about “herd immunity” (no pun intended). This is the resistance to the spread of a contagious disease within a population that results if a sufficiently high proportion of individuals are immune to the disease, especially through vaccination. We know that if you get 95% of a school immunized, the chances of the remaining five percent coming down with a virus is reduced remarkably because it stops the full outbreaks or spreading of the virus.
My understanding is that halacha, Jewish law, obligates you to protect other individuals in a community, not just yourself or your own family. Some Jewish anti-vaxxers misinterpret halacha to satisfy their own beliefs against vaccination. Or they may find the rare community rabbi who advocates against vaccinating, using this to strengthen their argument to satisfy their anti-vaccination belief.
IF: But aren’t there complications from the vaccine itself?
DRE: There is the possibility of a transient febrile (fever) reaction and a rash in 5 to 15% of vaccinated children. They may also get a sore arm at the inoculation site, typically lasting a few days and easily controllable with pain medicine such as Tylenol. There are rare events of allergic or other immune reactions, like transient joint pain. These are the risks you take when you get vaccinated with a living vaccine.
IF: What do you mean by a living vaccine?
DRE: There different types of vaccines. In the measles vaccine, the virus has been highly attenuated (weakened) by propagating the virus in laboratory culture tubes. It still can cause illness because it replicates once it is injected into the body. Other vaccines, such as whooping cough, tetanus, and influenza, do not replicate in the body, and do not cause symptoms similar to the infections they prevent.
Ultimately, it is always a risk-benefit analysis. This is an unconscious process that all humans do regularly. Don’t we risk going outside sometimes during a lighting storm? Don’t we get into cars, risking erratic drivers glaring at their cell phones while driving? Or flying in a “metal object” like an airplane 40,000 feet in the air? Or slipping in a bathtub and breaking a limb or worse? Aren’t there risks associated with these common activities?
Although the international scientific community has debunked the theory that measles vaccine causing autism time and again, the risk/benefit equation varies from parent to parent. There may be other arguments that a parent uses to reject a vaccine. Parents may distrust government; this is increasingly occurring now. They feel the government is in the hands of the pharmaceutical lobbyists and are being paid off in some way. They feel you cannot trust the government to tell us how and when to vaccinate our children. There have been studies showing that if certain parents believe this, even statistics and solid, scientifically-obtained data from thousands of persons will do nothing to convince them to accept the vaccine. No rational argument can persuade these parents. They can always construct their own rational reasons in their mind to advocate against vaccines.
Unfortunately, the only way to overcome their belief is for those parents to see someone suffer with measles or whooping cough, G-d forbid. They have to see it in an emotional way, not an intellectual way. The government likely cannot force people to vaccinate, but public venues can ask that those who do not vaccinate to be kept out so as not to bring the virus into the public. I was asked by a local Jewish day school if they should institute a policy of mandatory vaccination. I gave them an adamant yes! I believe other Jewish schools in town have already required vaccination in the face of outbreaks in New Jersey and New York. The constant movement of persons to and from Baltimore greatly increases the risk of infection.
IF: What should we be aware of when visiting public places, or attending simchas in communities where there may be an outbreak, such as in New Jersey or New York?
DRE: I was just approached by a local synagogue president who wanted to know if it is safe to let an unvaccinated child into shul. My response was that if we are sure that 95% of congregants have been vaccinated, I would not be concerned about letting that unvaccinated person into the congregation. Currently, we can feel safe in public places due to high vaccination rates in the general population and the current absence of measles in Baltimore, which would be a risk for 5% of the persons who have been vaccinated but have not responded to the vaccine. It’s not like SARS (Severe Acute Respiratory Syndrome) or the dangerous Ebola virus, for which we have no vaccine or immunity induced by prior infection. Thank G-d, there are currently no cases that I am aware of in the Baltimore Jewish community.
IF: What would you like to see happen regarding vaccines in Baltimore?
DRE: Well, it would be nice to know that students are being taught the pros and cons of
vaccination in a balanced fashion in health classes. I am not sure if this is discussed in local schools. I will tell you that I have just been sent the new vaccination policy of a local Jewish school. It clearly states and affirms that no family will be accepted to the school if they are unvaccinated without documented medical contraindication. All families must provide new and updated vaccination records required by the State of Maryland. The school does not recognize religious exemptions in this matter. This sounds like smart policy to me.
IF: Do you think the State of Maryland would get involved should there be an outbreak here?
DRE: I would hope they would. In Lakewood, because of the recent outbreak, the NJ State Board of Health has taken the initiative and set up vaccination tents where you are encouraged to walk in and get a vaccination. Do they say you can’t go to school if you don’t get a measles shot? I am assuming that, at this point, they are telling parents they can’t send their kids to school if they are not vaccinated.
If parents don’t want to vaccinate their children, they have the right to take their children out of school. There is a growing group of parents in Baltimore who homeschool their children. One reason may be because of the schools’ admission policy. They have formed their own social network to help justify and support their position.
IF: What other viruses are you aware of in the Jewish community?
DRE: We also have mumps. Mumps is epidemic in some Orthodox Jewish populations in New York. It has been found in young men in yeshivas. Why? It’s thought to spread when students speak face-to-face in learning via a small amount of secretions that spray out of their mouth which can infect their learning partner. But illness can be prevented if one gets the mumps vaccine. Another childhood vaccine is for rubella (German measles). As of 2016 it has been eliminated from the Western Hemisphere through use of the vaccine. But this doesn’t mean we should stop giving vaccines for rubella. We need to keep up the immunity to this virus because it can still come in from overseas and cause fetal death and severe congenital abnormalities in the fetus of unvaccinated pregnant women.
IF: Any final statements?
DRE: To summarize, the large majority of people who develop measles are unvaccinated. Measles is still common in many parts of the world, including some countries in Europe, Asia, the Pacific, and Africa. Travelers with measles continue to bring the disease into the U.S. Measles can spread when it reaches a community in the U.S. where groups of people are unvaccinated.
IF: Thank you, Dr. Edelman, for your time and expertise in this urgent medical matter.
Robert Edelman, MD, FACP, FIDSA, FASTMH, is Professor Emeritus in the Department of Medicine, University of Maryland School of Medicine. He is a 30-year member and Associate Director of the Center for Vaccine Development and Global Health (CVD-GH) at the University of Maryland, the largest academic vaccine center in world, which conducts research in over 12 developing countries.
SIDEBAR
Measles Stats and Facts
According to the CDC (Centers for Disease Control) website, there were roughly 6,000 measles deaths reported in the U.S. each year in the pre-vaccine era, before 1963. By 2000, measles was essentially eliminated in the U.S. via vaccination. Unfortunately, measles returned with small outbreaks among unvaccinated persons in 2008, 2011, 2013, 2014, 2015, and 2018. Many of the cases were associated with infected persons arriving from the Philippines and France. The majority of people who got measles were unvaccinated. In 2014, the U.S. experienced 23 measles outbreaks, including one large outbreak of 383 cases, occurring primarily among unvaccinated Amish communities in Ohio. In 2015, there was a large, multi-state measles outbreak linked to Disneyland in California. The outbreak was likely triggered by an infected traveler from the Philippines who visited the amusement park. In 2018, to date, 142 individual cases of measles have been confirmed in 25 states and the District of Columbia. This does not include the most recent outbreaks among more than 60 persons in Monsey, Brooklyn, and Lakewood, triggered by infected travelers from Israel.
