California health officials report on pertussis outbreak

Between January 1 and June 30, 1,337 pertussis cases have been reported to the California Department of Health, indicating an incidence of 3.4 cases per 100,000 population, according to data published this week.

Of 634 pertussis patients, 105 were hospitalized; 66 of these were younger than age 3 months. Incidence was highest among Hispanic infants than all other racial/ethnic populations, CDC officials said.

Health officials speculated that the gaps in California’s vaccination requirements for schoolchildren and inadequate insurance reimbursement for vaccinations may be a contributing factor to the outbreak. California is one of 11 states that does not require pertussis boosters for middle-school aged children.

Health officials in California are attempting to prevent the spread of pertussis to vulnerable infants by providing educational materials, offering clinical guidance, raising community awareness and offering free tetanus, diphtheria and acellular pertussis vaccine to birthing hospitals and local health departments. Writing in the Morbidity and Mortality Weekly Report, California health officials said they hope their efforts will support postpartum vaccination of mothers and close contacts of newborns.

CDC. MMWR. 2010;59: 26

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PERSPECTIVE

The California pertussis epidemic is on track to be the biggest in the state since 1958. As of mid-June, there were 910 confirmed cases, some 600 more suspected cases and five deaths, all in infants younger than 3 months. There is also this: California is one of a handful of states that does not require the tetanus-diphtheria and acellular pertussis booster for middle school entry.

Why doesn’t California have a mandate in place for middle school entry? From a public health standpoint, there is a clear case in favor of it. Pertussis immunity wanes after the childhood vaccination series ends. Adolescents are not only susceptible to pertussis, but they are a transmission vector for vulnerable infants. The clinical illness may not be a major concern for adolescents, but it is enormously problematic for infants—those five deaths to date in California demonstrate that fact.

Without even examining the specifics in California, I can comfortably guess at some reasons for the lack of a mandate there, because they are likely the same reasons we don’t have other necessary mandates — like influenza vaccination of every health care worker in this country. Among them: cost, access, under-appreciation of the potential morbidity and mortality associated with vaccine-preventable diseases and overestimation and misinformation about vaccine adverse events.

But here’s a reason that really makes me cringe — our society puts more value on personal choice than on protecting our fellow citizens. “Mandate” has become a dirty word. We don’t like mandating anything in this country. No, we’re not going to mandate and take away personal choice. But what choice did those five infants have? Does our thirst for individual freedom absolve us of our responsibility to protect them?

This problem becomes as much — or maybe more — of a political issue as it is a public health issue. There are so many reasons — too many reasons — why vaccine uptake is low, but one of them shouldn’t be the fueling of public health decisions by political fears.

Mandates assure that all are protected.

– William Schaffner, MD
President, National Foundation for Infectious Diseases, Bethesda, Maryland