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Vaccine refusal linked to large whooping cough outbreak

A new study found vaccine refusal played a role in the large whooping cough outbreak of 2010 in California. Find out how this applies to your child health.

Vaccine refusal linked to large whooping cough outbreak

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Vaccine refusal played a role in the large whooping cough outbreak of 2010 in California, found a study released today online from Pediatrics. That year, 9,120 cases of whooping cough were reported in California, the most since 1947.

In March, I wrote a blog about whooping cough, also known as pertussis.  The impetus for that blog was new data that had emerged regarding that California outbreak. Evidence available then suggested that waning immunity associated with the new acellular pertussis vaccine may have contributed to the outbreak.

Unlike many states, California requires only a parent’s signature on a form to permit a child to enter school without vaccinations.  The state keeps a record of these non-medical vaccination exemptions (NMEs). In California, pertussis is a disease that must be reported to the state health department. The authors of this study examined geographic clusters of NMEs and geographic clusters of pertussis cases to see if the clusters overlapped. The authors found that:

  • The average rate of NMEs per census tract in California averaged 2 percent between 2005 and 2010
  • 39 census tracts within the state had NME rates that were significantly higher than the rates seen in the remainder of the state
  • The odds of finding a cluster of pertussis cases within one of these census tracks with high rates of NMEs were 2.5 times higher than the odds of finding a cluster of cases in the remaining census tracts; this difference remained after the results were adjusted for a number of demographic factors.

So what does this mean? For an outbreak or an epidemic of an infectious disease to occur, a large number of individuals need to be susceptible to that disease and that disease needs to spread easily from person to person.  While vaccination reduces the risk of infection for individual recipients, it is estimated that vaccination of more than 95 percent of a susceptible population is required to prevent epidemics.  Small pox was eradicated through mass immunization; polio has almost achieved eradication by the same approach. 

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In California, the inability to protect more than 95 percent of the population from pertussis led to the 2010 outbreak. At least two factors contributed to this perfect storm.  Waning immunity in a vaccinated population rendered individuals thought to be protected susceptible to infection. Non-vaccination of a large number of individuals for non-medical reasons added even more susceptible individuals to the population. 

How does this apply to your child’s health? Vaccines are not 100 percent effective and as such do not provide universal protection.  Some vaccines may have protection rates as low as 60-70 percent.  However, if everyone around your child is immunized, the risk of exposure to an infectious agent is greatly reduced.  This phenomenon, called herd immunity, is perhaps the most important factor in protecting your child.  When children go unvaccinated for medical or non-medical reasons, the total population is placed at increased risk for infection.  This is the main reason that most states have stringent requirements for vaccination on admission to school. 

The take home message is to have your child vaccinated and to keep your child’s vaccination status up to date.  By not vaccinating your child, you are placing your child, your child’s classmates and the local population at risk for pertussis.


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Stephen Aronoff, M.D., M.B.A. Temple University Hospital
About this blog
The Healthy Kids blog is your window into the latest news, research and advice around children's health. Learn more about our growing list of contributors here.

If you have questions about your child's health, ask them here.

Anna Nguyen Healthy Kids blog Editor
Stephen Aronoff, M.D., M.B.A. Temple University Hospital
Christopher C. Chang, M.D., Ph.D Nemours/Alfred I. duPont Hospital for Children, Jefferson Medical Colg
Mario Cruz, M.D St. Christopher’s Hospital for Children, Drexel University College of Medicine
Katherine K. Dahlsgaard, Ph.D. Lead Psychologist - The Anxiety Behaviors Clinic, CHOP
Gary A. Emmett, M.D. Director of Hospital Pediatrics at TJU Hospital & Pediatrics Professor at Thomas Jefferson Univ.
Lauren Falini Bariatric exercise physiologist, Nemours/Alfred I. duPont Hospital for Children
Hazel Guinto-Ocampo, M.D. Nemours duPont Pediatrics/Bryn Mawr Hospital
Rima Himelstein, M.D. Crozer-Keystone Health System
Anita Kulick President & CEO, Educating Communities for Parenting
Janet Rosenzweig, MS, PhD, MPA VP for Programs & Research for Prevent Child Abuse America
Beth Wallace Smith, RD Children's Hospital of Philadelphia
W. Douglas Tynan, Ph.D. Nemours/Alfred I. duPont Hospital for Children, Jefferson Medical Colg
Flaura Koplin Winston, MD, PhD Scientific Director of the Children’s Hospital of Philadelphia’s Center for Injury Research and Prevention
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