Measles, it ain’t over until it’s over

Sally:           This is Sally Greenberg with the National Consumers League. I am joined here by Dr. Linda Fu who is a pediatrician and we’re going to be talking to her about vaccine issues and I’m joined by my colleague, Patricia Kelmer who’s our Senior Director of Health for the National Consumers League.

Patricia:       Thank you, Sally.

Sally:           Dr. Fu is an Associate Professor of Pediatrics at the George Washington University School of Medicine. She also serves as the Director of Academic Development at the Goldberg Center for Community Pediatric Health. Dr. Fu thank you so much for being with us.

Dr. Fu:         Thank you for having me here. It’s a pleasure.

Sally:           If we can start out with your description of your family background, how you decided to become a physician and we’ll just add that the National Consumers League has been working on medical issues and vaccine issues for a number of years and are very supportive of the medical community’s interest in getting everyone vaccinated, especially our kids.

Dr. Fu:         I am a general pediatrician. I practice in Washington, DC and I also spend a lot of my time on research and community based research. So about my background, when I graduated from medical school, about 20 years ago, I really had this feeling like I want to go out and help children, right? I think that’s why most people go into medicine. And I really felt that my reach is limited if I just treat the patient in my practice. And so I really felt I needed additional skills in order to reach a broader audience.

Dr. Fu:         And so I went back and got a Master’s of Science and Clinical Research focusing on community and population health. So that any messages that I could share with an individual family, I would have the skills to actually understand how I could broaden that reach. So after finishing that training, I thought, well, what’s the most important thing that I could study? I didn’t have a background in anything at that point and I truly feel to this day that the most important thing that we do in our pediatric practice has very little to do with me and actually more to do with the nurses. It is vaccinating children, it saves more lives, and it is more helpful and beneficial to children and everybody around them than the advice that I can give to families and then me poking around and doing my exam on them. So that’s my background, that’s how I got involved in this.

Sally:           Patricia?

Patricia:       I’m happy to hear that because what we’ve seen this summer is a large outbreak of measles and it seems like there’s more need than ever actually for the research and from the voices in the medical community to help us understand the importance of vaccination. So do you want to talk a little bit about your reaction to the events of the summer and this issue of outbreaks because people aren’t getting vaccines today?

Dr. Fu:         Right. It’s funny, when I started doing this, really my interest was in helping people get access, underserved communities and helping reach people who couldn’t get vaccines for whatever reasons. And what’s interesting is in, maybe the last decade or so, we’ve seen the issue isn’t so much that people can’t have access but there are personal barriers and knowledge and attitude barriers that are really preventing people from getting their children fully and themselves fully vaccinated. And so what we’ve seen is that it is slowly becoming more and more of an issue. We’ve seen the measles rates and outbreaks increase really over the last two decades. Measles was actually eradicated from the United States in the early 1990s, meaning literally there were no cases of measles in the United States and it was eradicated from other parts of the world as well, but due to international travel and pockets of people not being fully vaccinated, we’ve slowly seen increases here in our country, which is a huge shame.

Dr. Fu:         And then just this year, we’ve had more measles cases than we’ve had since 1992. There have been over 1200 cases of measles in the United States this year, which is such a shame.

Sally:           A lot of people think that measles is a common cold. Like you get it, you get over it, it’s not a big deal. I know I had it as a kid and my friends had it as kids. So there’s this theory out there that it’s better to get measles and get it over with and then you have lifetime immunity. What’s wrong with that theory?

Dr. Fu:         Well, so measles for most people can be something that is self-limited. But if you just think about those 1200 cases in the last year, 119 of those were hospitalized and 61 of them had serious complications, including pneumonia and brain infection called encephalitis.

Dr. Fu:         So it is not without risk. One thing that I will say is some people think, “well, then I’ll just get the disease.” But the risk of having complications from measles is one in 500. Whereas the risk of any reaction to any of the vaccines is one in a million to one in 2 million. So really, if you’re playing the odds, it makes a lot more sense to get vaccinated than to try to get the illness and be okay,

Sally:           Get the illness and well I’m of the era where we didn’t have a mumps vaccinations, we didn’t have measles, we didn’t have German measles vaccination, we didn’t have chicken pox vaccination. I know my son, who’s now 24 had all of those vaccines. So he never had any of those illnesses. Do you think we’ve in some ways a product of our own success and we’re suffering from the fact that we’ve pretty much eradicated a lot of these illnesses so we don’t see the effects?

Dr. Fu:         I think that’s definitely what the case is. Most of the diseases that vaccines protect against have been largely eradicated. These diseases were a lot more common about 50 years ago. And when you think about the people, making the decisions about vaccines for their children, they’re in their twenties and thirties, they don’t really know how terrible it was, and even I don’t. I’ve seen some of them, the diseases for which we’ve had later vaccines like meningitis, and those are horrible. And once you see them you really don’t want your child or yourself to contract something like this, but it’s this lack of memory and like anything, there’s a risk to vaccines, it’s infinite testimony, small, but there are risks and so when people think about that and they hear stories that are frightening, they don’t necessarily make a good risk benefit decision because it’s based on fear rather than pure numbers. We’re not computers, we don’t base things just on numbers,

Patricia:       It’s interesting, right, to think about the different reasons that people might have and the different generations. I can remember clearly my mother talking about friends that she had who had polio. That story was passed on to me but you’re right, today’s generation of parents don’t even have anyone in their lives who have seen someone’s struggling to stand because they’ve had polio and suffered from that.

Dr. Fu:         Even the grandparents now are of the age that it’s sort of rare for it to be seen and so it really is. We’ve been so successful.

Patricia:       Well, I think we have this false sense of security, right? We’ve eradicated this, we’re done. And so therefore I’m fine and the chance this risk, perhaps that seems to be escalated in the anti-vax community that may be getting a vaccine, might put you at risk, seems to be bigger than the risk of actually getting the disease. But as we saw in New York City, we had a tremendous outbreak. In fact, the United States I understand, was at risk of losing its WHO, the World Health Organization credential of being measles free and just missed that mark by a little bit. And how shameful that would be that this country that has the resources has worked very, very hard to make sure that everyone has access to important lifesaving vaccines is the one country that isn’t actually taking advantage of that access. So it’s concerning.

Sally:           So Dr. Fu and Patricia, my uncle had polio. He was in a wheelchair before I was born. He contracted it and I grew up with the knowledge that this destroyed the family, destroyed the family’s income and resources. He had spent two years in the hospital. He lost his work, his wife divorced him and my mother was in a constant state of mourning about her beloved older brother. And so I saw those effects but we also had a president with polio. FDR had polio and I was told about that and anyone can look and see our president in a wheelchair. I want to talk to you about how you talk to your patients. I think you said something really important a few minutes ago, and that is the chance that you’ll get measles is one of 500, the chance that you’re going to have a negative reaction and I asked you this when we met,

Dr. Fu:         Well, the chances of dying from measles if you have measles is one in 500.

Sally:           Dying from measles. So that’s a much bigger deal, dying from measles because as you pointed out, measles can have terrible side effects. I read a statistic about measles killing over 300 people around the world. Every single day. It’s a serious illness.

Dr. Fu:         It’s definitely endemic in other parts of the world and including parts of Europe. And so you think you’re protected, maybe you haven’t traveled internationally recently but the guy next to you in the deli line has and so you aren’t protected. Measles is highly contagious, meaning that you could actually just be in the same room as somebody who sneezes and catch it. You don’t actually have to touch something that they touched or drink from what they’ve drunk from.

Dr. Fu:         Although those are other ways that you could contract measles but just being in the same room, it takes that little exposure to contract the measles vaccine – sorry, the measles disease.

Dr. Fu:         It takes that little exposure to contract measles. And so you can’t bubble or wall yourself off from it.

Sally:           So there are people who are hesitant. You you’ve described it when you came and talked at our panel, you described vaccine hesitancy among your patients who just don’t really understand and think that there’s a greater risk than there is. And then there’s a very active orchestrated campaign to spread misinformation. So I think there are two different camps. Can you talk about that?

Dr. Fu:         That’s right. So not everybody for anything in life has the same perspective and so there isn’t just one specific way to talk to people about the issue.

Dr. Fu:         I think the thing, the only commonality is to approach from a place of empathy and understanding that people are concerned and they’re frightened and they’re not doing it because they think, for instance, that I’m a quack who doesn’t know what I’m talking about or I’m because they’re anti-establishment. They are afraid and you I see families and so I know that parents from talking to them, they’re concerned and want to do what’s best for their child. And so I think approaching people from that standpoint, not just in the clinical setting but when we have friends or family members who are afraid of vaccines, including my own mother-in-law. Approaching them from that perspective allows you to really listen to what the concerns are. People who are intent on not vaccinating and can’t be convinced, they won’t look at other sources other than ones that reaffirm their current perspectives. I think that’s difficult. And I don’t know of a way and I don’t think the scientific literature gives us any idea of how to approach those people.  But really who I’m talking about in terms of trying to reach personally in my life and in my practice are people who just need a little bit more information. They need time to be able to ask their questions and to hear answers from somebody who they trust.

Patricia:       I’m thinking a little bit about our role as Americans, right? We’re we have this strong pride in our ability to be independent and to have the freedoms that we want, right. But yet we’re also based on a democracy, which is talking about really working together and solving problems together,

Sally:           Community as well.

Patricia:       Community, the importance of community and the personal responsibility to the entity that we have here, our United States of America. And so I think about that also in terms of this decision of to vaccinate or not vaccinate, right. And I’m thinking in particular about the herd immunity and maybe you can explain a little bit about that and the decision of an individual not to get vaccinated actually has a broader community implication.

Dr. Fu:         That’s right. So what the outbreaks in of measles in New York has shown us is that even if the country is highly immunized, which we do have high immunization rates for measles, mumps, rubella vaccine overall. If a particular community has lower rates, those are the people who are going to interact with each other. And so, diseases can spread if there are pockets of under immunization. So when we talk about herd immunity, that means that enough members of a community are vaccinated such that they protect those who are not immunized either because they can’t because they are too young or too old or have weakened immune systems or also protecting those who choose not to vaccinate but you need a high level of immunization of the population to be immunized in order to achieve herd immunity and it really depends on how contagious, that disease is.

Dr. Fu:         But for most vaccine preventable diseases, we’re talking about 95 percent or so of the population that needs to be immunized. And again, we’re not talking about the entire United States, we’re talking in the local community of people who interact and so herd immunity to rely on that. One, I think as Patricia, you were saying earlier, we have this community mindedness, this civic mindedness where we protect those really to be part of the society and we should contribute and not just take from it. But it’s also just unreliable to think that herd immunity will protect you because something that’s also transmittable, I think are ideas. And so, if you’re saying this is not good, I’m not going to get my child immunized, what do you think is going to happen to the people that you’re talking to? And then the level of people who are protected and covered by immunizations will be down.

Sally:           So, let’s say I’m a patient and I’ve got or I the parent of several patients of yours and I come in and I go “Dr. Fu I’ve read about a link to autism on the internet and I have people telling me that putting some poison into my children’s bloodstream by getting them vaccinated and I’m worried about it. I don’t want necessarily believe them but you’re giving all these shots to this baby, how can you assure me that my child’s going to be here? My children are going to be protected. How does that conversation work?

Dr. Fu:         Right? So that is a long conversation and I have 15 minutes for an appointment. So that’s the challenge and the difficulty, which is why I encourage everybody who feels strongly about it to speak out because the anti-vaxxers are super vocal. And I think we have to be equally passionate in our communications.

Patricia:       There are great tools from on the CDC website that help individuals who feel strongly about the importance of vaccines to talk to others about it. And I think you’re right. Different people trust different people, right? So there might be individuals who don’t trust their healthcare provider as much as they trust their next door neighbor or their best friend. So we all have a role to play in the education.

Dr. Fu:         I completely agree, Patricia. And I also think in addition to having different people that you trust more or less hearing it from multiple different sources is really important. And I would say for myself, I know when my kids were growing up if somebody said they weren’t vaccinating, it’s really hard to work that in. Well, I think that you’re wrong. You sound a little bit conceited or know it all, I don’t know on the playground. So what I would say is, think about it at other times where it doesn’t feel so confrontational, it can be just part of the conversation, but it’s something that we have to think about. Again, if it’s an acquaintance, I think it’s sort of hard to confront somebody who is anti-vaxxer, but the whole idea is to just talk about it in general. The vast majority of people vaccinate their children. Anti-vaxxers makeup two to 3 percent of the population.

Dr. Fu:         It’s a very small percentage but they’re super vocal. There is absolutely no link between MMR vaccine or any vaccine and autism. That is completely unproven. Back to your question, Sally, what to do when somebody talks about the potential risks of vaccination. I’m very glad. I think that the media has a huge role to play in this. And I think I’ve seen more recently in media reports, less discussion about the discredited studies linking vaccines to autism and more about the issues that are scientifically proven. But to go into that a little bit, there was a study back in ’97 from a British scientist, Andrew Wakefield, it was published in the Lancets. It was found that he had a conflict of interest with this study and that there were methodological errors. Afterwards, all of his coauthors retracted, the Lancets pulled the article and he lost his medical license.

Dr. Fu:         But that one thing really just took off and people’s imaginations: since then there have been multiple, multiple studies that have shown no link between vaccines and autism. And actually more recent studies have shown signs and evidence of autism in utero. So prior to the baby even being born there can be [crosstalk] evidence. Right?

Sally:           Interesting. So there are other risk factors.

Dr. Fu:         When Andrew Wakefield published this study in the late 1990s, there was growing awareness about autism and actually diagnosis rates were increasing. And some thought was that healthcare providers were better at identifying it and then also by giving children this label. It allowed them to access more benefits at school and also more treatments through their insurance companies. And so there has been, they coincided. The other thing was that with autism you tend to lose your milestones and abilities.

Dr. Fu:         And so for instance, your language ability around the same time, just coincidentally as the age that the MMR vaccine is recommended. So a lot of people put this correlation together and assigned causation. But what we do know is that we continue to give MMR vaccine, the rates have not increased in terms of the rates of autism. And so that link is false, even from an epidemiologic standpoint.

Dr. Fu:         When Andrew Wakefield published this study in the late 1990s, there was growing awareness about autism and actually diagnosis rates were increasing and some thought was that healthcare providers were better at identifying it. And then also by giving children this label, allowed them to access more benefits at school and also more treatments through their insurance companies. And so there has been, they coincided. The other thing was that autism, you tend to lose your milestones and ability. So for instance, your language abilities around the same time, just coincidentally as the age that the MMR vaccine is recommended. So a lot of people put this correlation together and assigned causation. But what we do know is that we continue to give MMR vaccine, the rates have not increased in terms of the rates of autism. And so that link is false, even from an epidemiologic standpoint,

Patricia:       You know, I was thinking maybe Dr. Fu could talk a little bit about what it takes to become a vaccine, right? So maybe, maybe some of this question is people don’t really understand the science behind it and the many steps that have to happen before a vaccine can even make it to market?

Dr. Fu:         Sure. So it is a long drawn out process

Sally:           And expensive.

Dr. Fu:         Expensive process as well and one that we come to accept, we use so many medications and we don’t realize how much has gone into it beforehand. Actually, the U.S. has one of the most lengthy approval process for new medications in the world which is why sometimes treatments are available in Europe before they are in the U.S. but it is all for safety. So first are the preclinical trials in which vaccines are tested in the laboratory. That alone can last 5 to 15 years. That’s before it’s tested in any people.

Patricia:       That’s a long time.

Dr. Fu:         It’s a definitely long time and after that are the clinical trials and they start off small with just a few dozen people to see if it is at all dangerous in healthy people.

Dr. Fu:         And then they expand to a few hundred people to look at effectiveness, and then they expand to thousands of people. Again, all of this is prior to anybody in the public being vaccinated. It is all in the clinical trials. And then after all of those testings it’s not guaranteed to have FDA approval.

Sally:           Does FDA provides this process of clinical trials by the way, is it done according to the, their protocols or CDC’s protocols?

Dr. Fu:         Well, you have to. There’s a very strict process for the FDA to finally approve it. So you’d have to follow,

Sally:           Submit the research to the FDA for review?

Dr. Fu:         Exactly, for review and it had to have followed strict guidelines in order for it to finally be approved. And even after it is approved and out on market there is still a vigilance going on. So, public health authorities are monitoring for any sort of potential side effects and seeing whether that is any higher than in the background levels. And so it’s a very laborious process and it’s all done because vaccines are something that we give to healthy people. It is safer to take a vaccine than other medications because we have a higher standard because we know we are giving them to healthy people we have to make sure that it’s not just a slight benefit to receive them but a major benefit to give them to like our entire population.

Patricia:       So that kind of scientific rigor should help at least certain populations to understand that vaccines are safe. They wouldn’t be out there in the marketplace if they hadn’t gone through these stringent rules and regulations and proven their effectiveness. So of course that doesn’t convince everybody right. Science doesn’t convince everybody. So it is back to that individual messaging, it seems.

Sally:           Do you know who’s behind the really staunch anti-vax? I’m not sure I know. I’ve read some articles, but there seems to be a really strong, even though it’s very small, very vocal movement.

Dr. Fu:         I don’t remember the name of the family, but Lena’s son who was on that panel had written this fascinating expose that it was a particular family from the Washington Post that had contributed heavily to funding the anti-vax campaign and interestingly there were other stories about how Russians and Russian robots were spreading anti-vaccine stories on social media to so discord in our electorates. I think the source of the information is so important.

Patricia:       That’s frightening.

Dr. Fu:         It is very frightening but I think one thing – this goes back, we talk about educating parents at the pediatrician’s office and I think it goes even further.

Dr. Fu:         People make their decisions while they’re pregnant and so OBs need to be talking to parents and pregnant women.

Sally:           OBs meaning the doctors who take care of pregnant women?

Dr. Fu:         Exactly need to be talking to pregnant women. And I think it goes back even further to how we teach things in school. We talked about teaching civics to students. I think we need to be strong about that. We also need to teach them about social media literacy, where to get information and what makes something a credible source. I think all that’s important in order to restore trust in our public health systems.

Sally:           We all know that there are certain illnesses that none of us want to get. How do shingles present themselves? And isn’t there a connection between shingles and chickenpox?

Dr. Fu:         That’s right. So it’s caused by the same virus that causes chickenpox. And what happens is when you have chicken pox, it can stay dormant in your nervous system. And then for whatever reason, if you are body is challenged because you’re tired or because you’re older or because you are stressed. My brother-in-law actually got shingles when his wife went into labor and had a very difficult labor. So anything can cause it to re-emerge from the nerves and come out as a very, very painful rash, usually in one localized area on one side of the body. And it is extremely, extremely uncomfortable and can be debilitating for people and is also contagious. And so if you have shingles and are around, for instance my niece, my newborn niece, you can spread it to others as well. You can spread chickenpox. So the chickenpox vaccine protects against that in younger people and then the zoster vaccine protects elderly people from having this resurgence, I guess of this virus.

Sally:           Wait, are you calling anybody over 50 elderly?

Dr. Fu:         Yes. That was a poor choice of term.

Patricia:       Older is recommended

Dr. Fu:         Pretty close for me. So I’m not.

Sally:           I would never have guessed. So it is recommended for anyone 50 years and older, the shingles vaccine and it is two vaccines. That two shots that make up the full vaccine immunity that’s recommended and the new vaccine for shingles it’s considered to be much more effective?

Dr. Fu:         That’s correct. And so it is definitely a good idea for people to get that shingles vaccine, the new vaccine.

Sally:           Kids can’t get shingles.

Dr. Fu:         Kids can get shingles. It’s more common in not elderly, but older people.

Sally:           Just keep it to 50 and over would you please because older people are also very terrifying. The shingles vaccine has become so much in demand that there’s a low supply and it’s very hard to get a vaccination and you need two of them. I know because I ran out to try to get them when I had friends getting shingles and the first vaccine that came out wasn’t that effective but then science developed two new vaccines or vaccines that required two shots and you couldn’t find the vaccine because if you’re over 50, you realize, “Oh my God, this is the last thing I want to get. This sounds horrifying.” So you had the opposite effect where people saw the illness, they wanted to do anything they could do to avoid it. And so maybe that’s a good lesson for us?

Dr. Fu:         Right, because people have experienced it, it’s pretty common and so people know people who have experienced it, I will relay my own story. My faith in vaccines is so strong. About 10 years ago when there was the H1N1 flu I was pregnant and working in a hospital and so at high risk. And so I marched out with my toddler and my husband and we waited outside in a long line that wrapped around the Department of Health.

Sally:           You had to wait in a long line as a pediatrician? A pregnant pediatrician?

Dr. Fu:         Right. We didn’t have it at the hospital.

Dr. Fu:         And so we brought a little lollipop for my son when he finished. And so we get up there. It was finally our turn after about an hour and a half of waiting. And my son gets the vaccine, no problem. My husband gets his injection, no problem. And then they gave me my shot and actually for some reason it burst in the hub. And so they said, “Oh, okay, you probably didn’t get very much, let’s do it again.” So they gave it to me again, burst in the hub. And so I didn’t know how much of the vaccine that I had gotten, but, you know, I just.

Sally:           What does burst in the hub mean?

Dr. Fu:         Well, it just sort of, I don’t really know. It’s sort of sprayed all over the place. Some maybe went in me, some didn’t go in me. I think it must have been a defective syringe or something like that. But I went back to the Department of Public Health. We called the CDC and they asked whether I should get it again. They said it was up to me. I went back the next day and I got that vaccine. I gave it to my toddler son, I gave it to my unborn baby, but that’s how much faith I have in the system. It’s not something that I just recommend for my patients. It’s something that I live by too.

Sally:           Did you ever see somebody with the, who got the virus? The H1N1?

Dr. Fu:         Definitely, and in our hospital we, every year unfortunately have children in the ICU and most years at least one patient who dies from the flu. So it’s not something again where a lot of, I know a lot of people say, “Well, it’s not that bad. I don’t get it,” but why not take something that can help not only prevent death but reduce the chance of hospitalization and reduce the number of days of symptoms. That’s what the flu vaccine can do. So it may not be a hundred percent effective at preventing the flu but it will reduce the severity of symptoms.

Sally:           You know, you do hear from people. I mean, I have friends, Patricia, you probably do too. We all do who say “I never get a flu vaccine. The one time I got it, I got sick afterwards.” You hear a lot of this sort of folk wisdom or mythology out there. What can we do as people really care about community health, as Patricia was talking about public health work with the medical community to combat that kind of erroneous information?

Dr. Fu:         Right. If I had the magic solution, I would definitely tell everybody here today. I can quote the science and I’m happy to tell you what it is and I think it’s just hearing the message over and over again in whichever way you say it, that you’re passionate about. But what I will say is I hear that a lot from patients too that when I get the flu vaccine I get the flu. It is literally impossible to get the flu from the injection. It is not made out of live virus. And so what it is, is antigens, which stimulate your immune system to produce an immune response, same way when you get a common cold you don’t ever say, “Well, the cold gave me yet another cold,” right? It can’t. It’s your immune system reacting to the antigens.

Dr. Fu:         Some things that people say also is that, “well, it’s too many, it’s too much of a challenge.” People get exposed to more antigens that challenge the immune system from eating something that fell on the floor and then picking it back up from getting a cut on the arm, [crosstalk] it’s all around us. So one thing that I read, which I think is interesting is that if all the baby scheduled vaccines were given at once, it would use up slightly more than 0.1 percent of a baby’s immune capacity. So it’s nothing, it doesn’t overwhelm the immune system. It actually like anything, the more you are challenged, the stronger you become, which is why they say that kids who grow up on the farm or attend preschool actually are less likely to develop allergies later on or eczema later on in life because their immune system has been challenged.

Sally:           So if I pick up a tomato that fell on the floor and eat it, I’m actually helping my immune system probably because I’ve been known to do that. I’d been known to do such things.

Patricia:       It’s an interesting point because we’ve moved from the pediatric world right, to the older than a baby, right. There are lots of vaccines out there for people beyond babyhood. And so that’s another challenge in opportunity for us, I think to understand the opportunities to keep older people especially healthier by making sure that they have their own scheduled vaccines. And I don’t know Dr. Fu if you feel comfortable talking about that population as well?

Dr. Fu:         They’re definitely not who I immunized, but I definitely feel passionate about immunizations for adolescents and the elderly as well for the exact same reasons. They are vulnerable populations: adolescents in group living situations like college spread lots of things amongst each other and the elderly are weakened and can be more susceptible to complications when they get vaccine preventable diseases. So it’s really important. And what I think is interesting is that there’s a learning curve, not just for the public, but also for the healthcare providers. So if you have people in college, students health departments, as well as adult internists or family practice physicians who aren’t typically immunizing, a lot of people, they have the same biases as do the public because it hasn’t been something that they’ve necessarily kept on the radar unless they’ve had young children of their own recently. And so they’re learning as well as the public.

Sally:           Can you talk a little bit about – you talked about teenagers, so we’re in an era where we have this vaccine for HPV. How do you counsel your patients? You’re a pediatrician so your population probably goes up to about 18, until kids go off to college. Talk to me about how you talk to parents about that because there are some concerns by parents like, “are we encouraging our, our kids to be sexually active?”

Dr. Fu:         That was a concern early on that giving them the HPV vaccine might encourage your child that they’re safe and they don’t have to worry about sexually transmitted diseases and so they should they would have sex earlier. The epidemiologic evidence, there was just a study that came out recently. Teenagers are engaging in sex less and so the HPV vaccine has been out for over a decade and comparing, before it came out to recent data, there are fewer teens having sex than prior to the vaccine. So that has not borne out on a population level in the United States. And for some reason, I think how it rolled out in the messaging is so important. How HPV vaccine was introduced to the public. We’ve learned lot since then. I think because some of the concerns over the vaccination, I think it is very helpful in women.

Dr. Fu:         It is also helpful in men, but because it can prevent cervical cancer at first, it was approved for women and girls and I think that caused some confusion. “Well, why doesn’t my son need it? Why does only my daughter need it?” And so what we have now, even though HPV vaccine is recommended for boys and girls, so basically all,

Sally:           And you recommend it for your patients?

Dr. Fu:         I definitely recommend it and my own son again has had the HPV vaccine both doses.

Sally:           How old is he?

Dr. Fu:         I have a 12 year old and I have a nine almost 10 year old and he will get his vaccine on time too.

Sally:           When do you get the vaccine?

Dr. Fu:         It’s recommended at age 11 and 12 for boys and girls for boys and girls. And so what we have is the HPV vaccine coverage rates are lower than other adolescent vaccines by about 30 percent and even though it’s recommended for everybody and it can prevent cancer, if you think about a vaccine to prevent cancer, why are we not talking the vaccine?

Sally:           I’ll take a vaccine that prevents cancer.

Dr. Fu:         The recommendation for providers is to recommend same day, same way. So you recommend all the vaccines together because they have all been tested and are safe and effective. Millions of doses – we talked about the licensure post licensure of this vaccine, millions of doses have been given out and so it is safe in large population for over a decade.

Sally:           I think that’s incredible. Can I play devil’s advocate for a second? So meningitis, it’s very rare. We’re talking about maybe 24 cases a year across the country, but if it happens, you referred to it earlier, especially among dormitories where there are a lot of sharing of things and we’re going to say, we need to vaccinate everyone because 24 young people may get meningitis. Can you talk about the effects of meningitis and what your feeling is about vaccinating millions of people so that we can save a few lives?

Dr. Fu:         The meningitis vaccine for adolescents should be given at a age 11 with a booster dose at age 16. If you’ve ever seen a case of meningitis, it’s super frightening, bacterial meningitis because it comes on so quickly and turns very severe in literally hours. And so it cause death in a matter of a day or so. It’s a very frightening thing and so there are two meningitis specific vaccines and one is recommended for all children, men ACWY. And then there’s another one, men B, which, is recommended for people to talk with their physicians to arrive at a decision. Now, men B.

Sally:           That meningitis B?

Dr. Fu:         Meningitis B is actually more common than the other serotypes, the ACWNY serotypes but that one covers a bunch all at once, but it’s not any less dangerous.

Dr. Fu:         And all meningitis is super frightening and super deadly. And so the idea of having a vaccine that can be protective is really something that I think I talk about with my patients, like for my own children, I would want them to get this vaccine before they get to college. And really.

Sally:           Both meningitis?

Dr. Fu:         Both meningitis vaccines. Really it was an economic decision. The fact that the recommendation was for the men B to have a talk about it with your provider called a category B recommendation.

Sally:           Why isn’t that in your mind effective enough?

Dr. Fu:         Because we should be talking about all the vaccines with our physicians, right? So I recommend them all the same, the duration of protection for the men B vaccine is maybe less well known. So that’s the difference. However, again, on an individual basis for my own children, I would want them to get that vaccine if it offers protection and they’re going into an environment in which I know meningitis can spread, personally I would want that vaccination. And I think we should be talking to parents about all of their children’s vaccines and the adolescents about the vaccine

Patricia:       On the meningitis issue. I think it’s so very important. I mean, when you’re talking about these symptoms coming on so quickly and getting deadly, or debilitating so quickly, we all know college students, how busy they are, they ignore the symptoms, they figure they can sleep through it. Why wouldn’t we want to protect our kids from that experience? It just is unbelievable how quickly it can come through and cause devastating impacts. And unfortunately, it goes back maybe to that education, right? Are students in schools even learning about what’s to come in their health class, not just the birds and the bees but what is the role of vaccines? How do we keep ourselves healthy? Let’s not just treat diseases, but let’s keep ourselves healthy. And what’s the role of vaccines.

Sally:           And I want you to jump in on this Dr. Fu because you and I are on the same page on this. So I do confess that I walked into a room of meningitis, B families and I’ve never been the same since because the – Patricia talked about what it can do and people missing fingers, hands feet. One day they’re healthy, they go to sleep that night, call their parents from college, “I got a headache, I don’t feel good.” The parents say, you know, “go to sleep or go to the school nurse.” And the next thing, they’re in the intensive care unit and they’re lucky to live through the outbreak. It’s a small number. Can you talk about just the, the idea that we want to save lives and we want to vaccinate, even though the risk is small? It’s a hard sell because it’s an economic decision and these vaccines are not free.

Dr. Fu:         They are not.

Sally:           But if it’s my kid, I’m hoping that the CDC will help me save my children’s lives. The Washington Post did a story about all these parents who had lost kids and they were like, “my doctor didn’t tell me about the men B vaccine,” why not? And their kids are no longer alive.

Dr. Fu:         And to Patricia’s point in terms of education, there have been surveys of college students and they don’t think about vaccinations. They don’t know which ones they are doing overdue for and they don’t know the schedule. And that’s part of the transition of responsibility when kids go off to college. I think parents need to give them some limited autonomy and to involve them in decision making process, especially for their own health so that they can take the reins and, in a few years they’re the parents. And so that’s part of the responsibility that we need to teach parents to do for their children. For vaccine information, including the vaccination schedule, which changes from time to time, the best resource is the Centers for Disease Control and Prevention. So www.cdc.gov.  If you want more information about vaccine side effects and who they’re indicated for, www.humaneyes.org is another great website that can provide more information. The CDC I also wanted to mention has an app, which can remind you when vaccines are due. So there’s a lot of good resources out there. The last place that I would recommend is the American Academy of pediatrics@ap.org for more information about vaccines as well.

Patricia:       Right. I remember sending off my kids to college and having them snap a shot of their immunization record so it’s on their phone all the time.

Dr. Fu:         That’s great. That’s something that I recommend too.

Sally:           And these vaccines how much do they cost the system? Do we have any idea of like the men B or the HPV and they’re covered by insurance are they not?

Dr. Fu:         They are covered by insurance and with the affordable Care Act currently vaccinations are required to be covered. The issue I think for adolescents who are in college is that they may be someplace where they’re not able to access a provider who’s in network and so that’s why it’s important to sort of figure these things out before kids go to college, because then the cost is very high but the vaccines are covered by insurance plans.

Patricia:       Yes, and when you think about the cost I was looking at the statistics of how much it costs New York City to contain that measles break – $6 million. They had to deploy 500 individuals into those four Boroughs in Brooklyn just to contain that outbreak. So the cost is high, not only in human lives and illness but in trying to contain outbreaks if we’re not doing our part in protecting with a vaccine.

Dr. Fu:         Compared to our other public health initiatives, they are extremely cost effective and that’s something that maybe we don’t talk about enough but it definitely in terms of human productivity and worker productivity as well are extremely cost effective as well. But that’s not to say they’re not also protective in terms of human lives. 322 million cases of vaccine preventable diseases have been prevented since the first immunizations were approved and that’s also 700,000 deaths in children alone that have been prevented from vaccines.

Sally:           I do want to ask you how many adverse effects from vaccines have you seen in your pediatric practice?

Dr. Fu:         So in my own practice over the last maybe 20 years and including those colleagues who I practice with and I practice in a large practice with about 50 other providers and our health centers, I have not seen any cases of a vaccine preventable disease and that is talking maybe tens of thousands or hundreds of thousands of patients over the years.

Sally:           And no adverse effects?

Dr. Fu:         No adverse effects and neither of my colleagues.

Sally:           Dr. Fu thank you so much for what you do. I know you work in an urban part of Washington, DC and deal with an underserved population and you’re doing a real public service. We can’t thank you enough for taking the time to do this podcast with us and for what you do every day for your patients. So thank you for your leadership and for being a friend of those of us who believe very strongly in the efficacy and safety of vaccines.

Dr. Fu:         Thanks, it has been fun.