Lawrence B. Palevsky - False Alarm Over Pertussis "Outbreak"

A Letter from Lawrence B. Palevsky

In an October 2011, the Suffolk County Health Commissioner published a Health Advisory stating that 179 cases of pertussis have been reported to the NYS Department of Health this year, compared with 54 cases in 2010 and 75 cases in 2009.Click Here to Read Report 

In response to the following news report (Click Here to Read Report), Tribeca Pediatrics in NYC wrote a letter to the patients in their practice warning them that the number of cases of pertussis infections in Suffolk County has now surpassed 200. An alarm has been raised in the public arenas about this surge in cases of pertussis infections. I'd like to take this opportunity to raise a few points and answer a few questions about this sudden alarm, which appears to be more like a false alarm than anything else. 

1) It is well known that the number of reported cases of pertussis is much lower than the number of actual cases of pertussis. I'm not trying to be an alarmist here, but the number of actual cases of pertussis infection may be even higher than what has been reported to the Department of Health. This occurs because not everyone who has a case of pertussis presents with the classical symptoms of a pertussis infection. Children and infants can experience upper respiratory infections and not know they have a pertussis infection, and their illnesses are simply reported as run-of-the-mill "colds and coughs." No report is, therefore, made to the Department of Health. And, not everyone who has an upper respiratory infection caused by pertussis seeks medical care. Therefore, it is hard to know the exact number of true cases of pertussis in a community. It's difficult to know if the jump in the number of reported cases between 2010 and 2011 reflects a true jump in actual cases of pertussis infection, or is simply a variable of different diagnostic abilities and reporting efficiency to the Department of Health from year-to-year. It's possible that the previous year's numbers of cases were really much higher than 54 & 75, and the cases simply went unreported. It's also possible that the number of actual cases this year is lower, or the same as the last 2 years. In 2011, the number of true cases of pertussis infection in Suffolk County may be even higher than the 200+ cases so far reported, but we are no worse off for it. The number of reported cases depends on the ability of parents and physicians to recognize the symptoms of pertussis infections and properly report them to the Department of Health. With all the variables discussed above, I don't know what to make of the significance of these data, other than to see it being used to scare people into believing that something new and alarming is occurring.

2) How many of the over 200 reported cases have been in the pediatric population, and how many have been in the adult population? Unfortunately, I don't know the answer to this question, but it's important to know the answer.

3) How many of the over 200 reported cases of pertussis occurred in partially or fully vaccinated children, and how many occurred in unvaccinated children? Unfortunately, I haven't been able to find the answers to this question either, but in the majority of the recent reports of community outbreaks of pertussis infections around the US, anywhere between 45% and 82% of the children who were reported to have had a pertussis infection were also fully vaccinated. Not exactly a good success rate for the pertussis vaccine to protect against a pertussis infection. 
If physicians and the Department of Health are using tactics to scare people into getting vaccinated because over 200 cases of pertussis have been reported in Suffolk County, it is only fair to the public to present them with the full picture of what is going on. We need to know the percentage of children who were vaccinated and came down with the pertussis infection anyway. This information would make it easier for parents to weigh the risk-benefit ratio before deciding to get or forego the vaccine for themselves or their children. If a large percentage of children are vaccinated, and are reported to get the pertussis infection anyway, it would seem obvious to most that improving vaccination rates does not seem to be an effective intervention to prevent against further pertussis infection, especially since vaccination rates for pertussis are already so high (see below). A pertussis outbreak due to vaccine ineffectiveness, or bacterial mutation, should not be followed by increasing the numbers of vaccinated people. This doesn't make sense. Simply reporting the total number of cases of pertussis without reporting their vaccination status is also incomplete, and misleading to the public.

4) How many children live in Suffolk County? According to the 2010 Census Bureau, there are about 1.5 million people living in Suffolk County. Children under 18 are estimated to make up about 1/4 of the total population, or about 375,000 children. Even if all 200 + cases of pertussis in Suffolk County this year have occurred in children under the age of 18, we're really only talking about .05% of the population of children coming down with pertussis infections so far this year. This is no where near the kind of outbreak that warrants such urgency to get children and adults vaccinated immediately. The numbers do not even speak to a true outbreak. There is no need to panic or act out of fear.

5) What percentage of the total population of children is vaccinated with the pertussis vaccine? It's hard to know exactly within each community since each region has different demographics, but according to data from the CDC National Immunization Survey, estimated DTaP vaccination coverage of children 19-35 months old in NYS in 2010 was 95% for 3 doses and 84% for 4 doses of the pertussis vaccine. For 19-35 month old children living in NYC, the estimated coverage rates for 2010 were 92% for 3 doses and 75% for 4 doses. (Click Here for Reference). These are extremely high coverage rates, and we are taught that 3 doses of the DaPT vaccine is sufficiently effective to impart protection against the pertussis infection. The estimated TdaP vaccination coverage of teenage children in NYS in 2010 was 84%. The coverage for teenage children in NYC in 2010 was 82%. (Click Here for Reference ).

According to the National Network for Immunization Practices, it is estimated that 3 per 1000 children remain unvaccinated nationwide. (Click Here for Reference). If we apply this estimate to the population of Suffolk County, out of the approximate 375,000 children living there, about 1,125 children would be unvaccinated. There is no evidence that vaccination rates in Suffolk County have dropped to such low levels that an increased number of unvaccinated children is to blame for the increased number of cases of pertussis infection. Many physicians, parents and public health officials are quick to point to the unvaccinated children as the cause of increased outbreaks of pertussis, or the cause of outbreaks of any other disease. Unfortunately, parents are misled into believing that unvaccinated children pose a risk to vaccinated children. This makes no medical sense, and is an inaccurate assessment of the science. 

Pertussis bacteria live in the air. They get blown around along with the other trillions of bacteria that live in the air. Because pertussis bacteria live in the air, we breathe them in along with the other trillions of bacteria swirling around. They end up inhabiting our noses, airways, and lungs. We can be harboring pertussis bacteria in our airways simply by breathing the air.

Do pertussis vaccines prevent children and adults from breathing in pertussis bacteria from the air? 

Do children vaccinated with the pertussis vaccine somehow stop carrying pertussis bacteria in their airways simply because they've been vaccinated?

Do pertussis vaccines stop vaccinated children from transmitting the pertussis bacteria to other people? 

Do pertussis bacteria disappear from society once vaccination rates are high?

Vaccination rates for pertussis have no impact on whether the pertussis bacteria are in the air or not, or whether or not we breathe them in. The presence of the pertussis bacteria, and the exposure to them, are in no way affected by vaccination status or vaccination rates.

Do unvaccinated children, because they are unvaccinated, carry the bacteria in their airways, which vaccinated children are somehow no longer believed to be carrying because they've been vaccinated?

Do unvaccinated children transmit the pertussis bacteria to other children by the mere fact that they are not vaccinated?

Air is air. Air is free to breathe. We breathe in whatever is in the air. And, vaccinated and unvaccinated children are equally exposed to breathing in pertussis bacteria. Anyone who poses as science the idea that unvaccinated children pose a threat to the population because they are unvaccinated and are more likely to transmit a disease to the rest of the population, is misleading you, promulgating myth, and inaccurate. Vaccination with the pertussis vaccine does not exonerate anyone from carrying the pertussis bacteria, or prevent them from being exposed to the bacteria.

Can children and adults carry the pertussis bacteria in their airway and not be sick with the infection? 

Exposure does not equate to infection.

Is it more likely than not, due to the trillions of bacteria that are in the air, that most people are inhaling pertussis bacteria into their airways on a regular basis without knowing it and without getting infected by them?

Are we made to believe that the pertussis bacteria are only present in the community when children and adults come down with the actual pertussis infections?

Is this true?

Pertussis bacteria are present in the community even if no one is suffering from a pertussis infection. It is safe to always assume exposure to the bacteria from the air, regardless of vaccination status.

Can pertussis bacteria already be inside our airways before we even catch the illness?

If the bacteria can already be inside our airway before we come down with a pertussis infection, does that mean that it's possible that "catching" the disease from someone else may not be how the illness gets started?

Is it possible that the pertussis bacteria, living in a relationship with all the other bacteria in the airway, and in relationship to the immune system in the airway, can become activated, and invade the body to cause illness, without catching it from another person? 

Always consider that we can be exposed to these bacteria, they can live in the airway, and we often avoid being infected by them regardless of whether we are vaccinated or not. And, to repeat, this has a lot to do with the fact that exposure does not equate to infection. It's true for pertussis, and it's true for the trillions of other bacteria that are living symbiotically on us and in us throughout our body, without infecting us.

Consider the possibility that vaccinated and unvaccinated children alike, despite breathing in the bacteria and colonizing their airways with all types of bacteria, might avoid getting pertussis infections due to factors having nothing to do with their vaccination status. In other words, children vaccinated with the pertussis vaccine may not get a pertussis infection, and their protection from the disease may have nothing to do with the protection believed to be given to them from the vaccine. Similarly, children who are not vaccinated may not get a pertussis infection, and the reason for their protection from the disease has nothing to do with how many children are vaccinated (herd immunity). Children can still be exposed to the bacteria, and not get the disease for reasons having to do with the health of the conditions inside the immune system of their airways that is already symbiotically living alongside the colonized pertussis bacteria. 

What makes the pertussis bacteria become active, replicate, and invade the airway lining of our bodies is a topic for another discussion, but it's important to recognize that exposure to the bacteria is more than likely happening for everyone, and that doesn't necessarily equate to infection. There is nothing to be alarmed about.

Keep your children safe and warm in the winter. Eat warm, hearty foods. Sleep more. Rest more. Do less. Slow down. 

And, Happy Holidays.

Dr. Larry

Lawrence B. Palevsky, MD, FAAP, ABIHM

www.drpalevsky.com