Wednesday, February 4, 2015

Disease continues to exist in the world

First published in the California Tech on February 2 2015

Disease continues to exist in the world

Casey Handmer

How many of us personally know someone who has suffered from a vaccine-prevented disease? Ask your grandparents.

As of Jan. 30, California's very own measles outbreak has reached 91 confirmed cases. Centered at Disneyland, cases are now known in seven states. Measles, like nearly every other disease, is well controlled in the US and other developed nations. Despite its current rarity, measles remains one of the most contagious diseases, comparable to the cold. Contact with moisture containing the virus has a 90% infection rate even hours after emission, and a number of cases have originated from doctors' waiting rooms.

Before measles was controlled, it infected about 4 million people per year in the US. Roughly 1 in 100 cases required hospitalization, 1 in 1,000 led to encephalitis, and 1 in 10,000 were fatal. You might think a vaccine that reduces overall risk by even 10% on these numbers would be universally popular, but you'd be wrong. Anti-science and anti-vaccination ideology cuts across traditional political or socio-economic lines: parental choice is to blame for these and other outbreaks, including numerous fatal infant cases of whooping cough.

Modern vaccines, like any medical procedure and life in general, contain risks. We accept those risks because they're incredibly tiny and because universal vaccination prevents the disease from spreading and infecting vulnerable people. The very young, the very old, and the immunocompromised are sitting ducks and can only be protected by herd immunity.

It is not clear how to enforce vaccinations in children without legal compulsion. Parents rightly control their children's health decisions, and almost always make correct, informed choices. Yet the recurrence of preventable diseases in the US, UK, and other developed nations has failed to arrest the falling incidence of vaccinations.

It is especially mystifying when compared to the widespread hysteria surrounding the Ebola outbreak in 2014. Ebola, while much deadlier, is much less contagious than measles or flu, and comparatively easy to control, despite the lack of an effective vaccine, via contact chaining. Grounding of flights from Africa was seriously considered as a way to prevent supposed Ebola-ridden zombie hordes from overrunning the US. But any legislation that compels MMR (measles, mumps, rubella) vaccination or even protects schools' rights to restrict enrollment based on vaccination status is a political impossibility.

In contrast, the battle to control HIV/AIDS appears to be turning a corner. HIV requires specialized tools to diagnose and treat. In developed countries, case-by-case epidemiological control has kept incidence below 1 in 100, with many sufferers concentrated in certain underserved and/or high risk communities. This wasn't always the case. The 1980s saw a period of denial and false assumptions wherein people, usually of more privileged backgrounds, unaccustomed to untreatable disease, refused to accept the science and subsequently died, but usually not infecting others in the process. This began a cultural change wherein my generation assumed principles of safer sex practices as axioms ("no glove, no love") rather than an imposition. It is sadly unclear how many babies will have to die of measles or whooping cough before failing to vaccinate children becomes as socially unacceptable as sleeping around without protection.

HIV in the developing world is a different story. Infection rates in Sub-Saharan Africa have climbed into double-digit percentages, often afflicting children since birth, due to poor access to prevention, treatment, and education. Without a vaccine, disease control strategies have focused on the distribution of antiretroviral therapy (ART) drugs which can dramatically reduce the risk of transmission, particularly mother to child, in combination with education and, where politically possible, the promotion of condoms. The process is technical, messy, complicated, and ever changing. Like vaccines, misinformation about the efficacy of condoms spread by unscrupulous or ignorant interests has an outsized effect at the global scale.

According to the Joint United Nations Programme on HIV/AIDS, 2013 was the first year in which the number of new infections was smaller than the number of infected people starting to get treatment. This is an important milestone in that the number of untreated people has peaked and will, with continued effort, continue to fall. But with 35 million people living with HIV, 13 million receiving treatment, 1.5 million deaths and 2 million new infections a year, there is a long way to go.

In the US, we enjoy a life so prosperous, healthy, and risk free it was simply unimaginable to our grandparents. This did not happen by chance. Maintenance of historical gains and continued improvement in public health will require ongoing investments of time, money, and expertise.

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