My recent blog post on eradicating polio through vaccination ends with this:
Part of the reason why vaccination is challenging is because social networks play a critical role in disease transmission. Even if enough people have been vaccinated in aggregate to obtain herd immunity in theory, it may not be enough if there are hot spots of unvaccinated children who can cause outbreaks. There are hot spots in some areas in California and other states that have generous exemption policies.
I want to elaborate. It’s possible that we have both:
- record levels of immunization, and
- record levels of vulnerability to highly infectious diseases.
The CDC estimates that 95% of kindergarteners have had MMR and DTaP immunization and 93% have had varicella (chicken pox) immunization. [Link] And yet there are outbreaks! The CDC’s immunization goal is 95%. Given that some kids truly should not be immunized (like those with specific allergies or those who have had serious reactions to other vaccines), there isn’t much room to allow for parents to choose to opt out while maintaining herd immunity. In fact, just a few people opting out has been linked to several disease outbreaks [Links here and here]. This is especially critical for newborns, who cannot be immunized for anything except Hepatitis B, and babies under a year old who cannot get the MMR vaccine for the measles. There is a measles outbreak among babies who cannot be vaccinated against the measles yet in a Chicagoland day care. In other words: please vaccinate your children if you can.
<side note>The rotavirus vaccine was off the market from 1999 to 2006, so my oldest daughter wasn’t vaccinated. She came down with a bad case of rotavirus at age 3.5 when my second daughter was 3 months old. Luckily, my second daughter had received her first rotavirus immunization 2 weeks prior and didn’t get sick.<\side note>
Despite having record levels of immunization, we’ve seen a lot of cases of pertussis, measles, and other infectious diseases. It’s all about social networks!
Let’s return to herd immunity. Estimates from Wikipedia indicate that most diseases require an immunization rate of 85%-94% (the herd immunity threshold) in a “well mixed” population to achieve herd immunity. In other words, this might be an optimistically low threshold when kind of ignoring social networks. An article in The Atlantic reports a 92% herd immunity threshold for most diseases and a 95% herd immunity threshold for highly infectious diseases like the measles (they cite a World Health Organization document). A population being well-mixed is a big assumption. Kids within the same school may travel in different social circles that are more homogenous than the school as a whole. That’s important. A social circle that has a low level of immunization may introduce risk to the kids in the community even if the school as a whole is above the herd immunity threshold. That’s what happened in the Chicagoland day care with the unvaccinated babies who hung out together every day. But more generally, people who don’t vaccinate generally have friends who also don’t vaccinate.
The Guardian has a nice simulation about herd immunity and social networks. They consider a few different communities with different vaccination rates (from 10% to 99.7%) with vaccinated, unvaccinated (susceptible) and vaccinated but susceptible individuals (the CDC estimates that MMR only “takes” in 93%-97% of those vaccinated). A few random individuals then come in contact with the measles. The red individuals represent infections. There are measles outbreaks even with a 90% vaccination rate.
The Guardian simulation results for exposing a community to measles. Sometimes a vulnerable community is OK (see the 83.8% vax rate here) but in general there is an outbreak.
We need vaccines because they protect against highly contagious diseases. Epidemiologists use the “basic reproduction number” (R0) to estimate how infectious a disease is, where R0 is the average number of people someone with the disease is expected to infect. The smaller R0 is, the less a disease tends to spread. Exponential growth happens when R0 > 1, but there is exponential growth (flu R0=2.5) and then there is exponential growth (measles R0 = 16!!). While R0 can be lowered by actions like good hygiene, some diseases are inherently more contagious than others. We can’t get the measles to spread as “slowly” as seasonal flu no matter how much we encourage people to wash their hands and use hand sanitizer. This is why we need vaccines as well as a higher herd immunity threshold for diseases like measles than we do for the flu. When that one person who hasn’t been vaccinated infects 12-18 other people, we have an epidemic on our hands. From the Wall Street Journal:
“Imagine if you had a reproduction number of 15 for measles with everybody susceptible,” said Derek A.T. Cummings, a professor of epidemiology at Johns Hopkins Bloomberg School of Public Health. “If you go in and vaccinate half the people, the expected reproduction number goes down to 7.5.”
The Guardian provides a nice figure of deadliness (the y-axis) vs. the basic reproduction numbers (the x-axis) of various diseases. That cluster of diseases on the right hand side is composed of highly infectious. Measles, rotavirus, whooping cough are highly infectious in ways that the seasonal flu just isn’t. In fact, the CDC recommends vaccines for that entire cluster of highly infectious diseases over there on the right except for malaria (which isn’t a huge problem in the US) because they are really that bad.
Deadliness vs. Basic Reproduction Number.
I get the impression we keep having these debates without agreeing on what the problem is and what its consequences are. It’s reasonable to say that most people in my generation have no idea what a massive infectious disease outbreak looks like. It’s not like the seasonal flu, where you know just a few people who succomb to the flu every year but you’re usually OK. With these highly contagious diseases, outbreaks may be rare but then BOOM, everyone you know is sick. Chicken pox (R0 = 8.5) may be an exception. The chicken pox epidemic in my kindergarten class was the only time I experienced a massive infectious disease outbreak (class attendance dwindled to 3-5 students for a few days).
<side note>I may have had the mildest case of the chicken pox ever recorded. I had just a few poxes/blisters and itched for maybe an hour. But I bear a scar on my face from one of the few poxes I had(!) </side note>
I’ll stop here for now. Let me know your thoughts on vaccination, social networks, herd immunity, and disease outbreaks.
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February 9th, 2015 at 4:44 pm
I had a medium case of chicken pox when I was 3 (it went through my preschool class). I also infected my mom, who hadn’t gotten it as a child, and my infant brother. My mom had a really awful time-pox in her throat, etc, and my brother was so little that even though his case wasn’t particularly bad, he has several scars now because it’s hard to get a 4-month-old to stop scratching when he itches.
My sister, who wasn’t born yet when I infected our family, was in late elementary/middle school when the vaccine came out, and my mom had her vaccinated as soon as our pediatrician thought the vaccine had been around long enough to be considered safe. She didn’t want her to have the misery of getting it as an adult. Even though none of us had complications, it was miserable, and it seems wrong not to prevent that misery if we have a safe vaccine.