Editor's Note: The writer is a pharmacist at Tiffany Natural Pharmacy, an independent community pharmacy in Westfield.

Removing religious exemptions could help suppress vaccine-preventable illness outbreaks and save lives.

After reading the introductory paragraph numerous times, I was still unable to grasp what the author was attempting to communicate. I was simply left with further questions. What did Robert F. Kennedy, Jr say during this debate? And who is this “educated vaccine proponent” I really respect? Nonsensical, opening paragraph aside, the author then goes into her fundamentally misunderstood and misguided views of the potential public health threats posed by vaccine hesitancy.

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The author begins with her misunderstanding of herd immunity. Herd immunity is not a belief or belief system, like religion or alternative medicine. The term herd immunity was first used in 1923.[1] It was first recognized as a naturally occurring phenomenon in the 1930s when it was observed that after a significant number of children had become immune to measles, the number of new infections temporarily decreased, including among susceptible children.[2],5 In 1933, Dr. Arthur W. Hedrich, a health officer in Chicago, IL observed that during 1900-1930, outbreaks of measles in Boston, MA appeared to be suppressed when 68% of the children contracted the virus.[3] Subsequently, in the 1930s, Dr. Hedrich observed that after 55% of the child population of Baltimore, MD acquired measles, the rest of the population appeared to be protected. It was that observation that formed the basis for mass vaccination campaigns.[4] Mass vaccination to induce herd immunity has since become common and proved successful in preventing the spread of many infectious diseases.[5] Opposition to vaccination has posed a challenge to herd immunity, allowing preventable diseases to persist in or return to communities that have inadequate vaccination rates.[6],[7],[8]

MORE: Westfield Health Officials Back bill to Cut Religious Exemptions on Vaccinations

The next fundamental misunderstanding concerns immunology. Vaccines are typically imperfect as some individuals' immune systems may not generate an adequate immune response to vaccines to confer long-term immunity, so a portion of those who are vaccinated may lack immunity.1,[9],[10] In addition, some individuals either cannot develop immunity after vaccination or for medical reasons cannot be vaccinated.[11],[12],[13] These populations could potentially be very vulnerable to contracting vaccine-preventable illnesses.

Well-developed vaccines provide protection in a far safer way than natural infections, as vaccines generally do not cause the diseases they protect against and severe adverse effects are significantly less common than complications from natural infections.[14],[15] The immune system does not distinguish between natural infections and vaccines, forming an active response to both, so immunity induced via vaccination is similar to what would have occurred from contracting and recovering from the disease.[16]

Certain bacteria, for instance, Hib meningitis can spread even when a person is asymptomatic. That is, you can’t tell who’s contagious.[17] The author then delves into “vaccine shedding.” Vaccine shedding is a term used for the rare release of virus following administration of a live-virus vaccine. Shedding is a popular anti-vaccination trope[18],[19], but, with the exception of the oral polio vaccine (OPV) in the 1950s, there have only been a few documented cases of vaccine-strain virus infecting contacts of a vaccinated person.[20] Viral shedding is part of the mechanism of virus transmission.[21] Shedding is impossible with killed vaccines or those made using only isolated proteins (most vaccines fall into one of these two classes), but a small number of vaccines contain live attenuated virus, which can theoretically infect others. Not all pathogens are shed, shedding does not equal transmission, and transmission does not always cause disease.

MORE: Preventing the Mumps: What You Should Know

The author then wrote about the passage of California bill SB277, which was passed in 2015 due to the 2014 Disneyland measles outbreak, in which at least 40 visitors contracted measles at the park between December 17-20, 2014, and low levels of vaccination in pockets of California.

After claiming a 17% rise in autism in the following year, I searched for any evidence to back these figures but was ultimately lead to The Daily Messenger, a blog containing the conspiracy-riddled ramblings of a religious zealot from California.

The author then shifts her focus to another vaccine-preventable disease, mumps. When a mumps outbreak hit Harvard University in 2016, epidemiologist Joseph Lewnard and immunologist Yonatan Grad, both at the Harvard T. H. Chan School of Public Health in Boston, wanted to know why.

They saw two possible explanations for the outbreaks: either today’s mumps strains have evolved to elude the immune response triggered by the vaccine or protection from the vaccine simply wanes over time. Immunity to mumps lasts about 16 to 50 years or about 27 years on average. That means as much as 25% of the vaccinated population can lose immunity within eight years and 50% within 19 years. The team then built mathematical models using the same data to assess how declining immunity might affect the susceptibility of the U.S. population. When they ran the models, their findings lined up with reality. For instance, the model predicted that 10- to 19-year-olds who had received a single dose of the mumps vaccine at 12 months were more susceptible to infection; indeed, outbreaks in those age groups happened in the late 1980s and early 1990s. In 1989, the Centers for Disease Control and Prevention added a second dose of the vaccine at age 4 to 6 years. Outbreaks then shifted to the college age group. Lewnard and Grad did not find evidence that the vaccine is any less effective today than it was a half a century ago. If that were the case, they would have expected to see outbreaks in younger people, which aren’t happening.

The researchers say future mumps outbreaks could be prevented by giving all 18-year-olds a third dose; they recommend clinical trials to test whether that approach works. Already, the U.S. Advisory Committee on Immunization Practices has recommended that people exposed to outbreaks get a booster shot. “You can see that when we give these vaccines during outbreaks, the outbreaks stop,” says Laura Pomeroy, a disease ecologist at The Ohio State University in Columbus who was not involved in the study. The strategy has also worked well for the military, which has not seen mumps outbreaks since it began giving all new recruits an MMR dose in 1991.[22]

Afterward, the author attempted to justify her views by downplaying the real dangers associated with vaccine-preventable, infectious diseases with “How threatening is measles really?”

Complications of measles are relatively common, ranging from mild ones such as diarrhea to serious ones such as pneumonia (either direct viral pneumonia  or secondary bacterial pneumonia), bronchitis (either direct viral bronchitis or secondary bacterial bronchitis), otitis media[23], acute brain inflammation[24] (and very rarely subacute sclerosing panencephalitis[25]), and corneal ulceration (leading to corneal scarring)[26]. In addition, measles can suppress the immune system for weeks to months, and this can contribute to bacterial superinfections such as otitis media and bacterial pneumonia.[27],[28],[29] The death rate in the 1920s was around 30% for measles pneumonia.[30] People who are at high risk for complications are infants and children aged less than 5 years; adults aged over 20 years; pregnant women[31]; people with compromised immune systems, such as from leukemia, HIV infection or innate immunodeficiency31,[32]; and those who are malnourished or have vitamin A deficiency.31,[33] Complications are usually more severe in adults who catch the virus.[34] Between 1987 and 2000, the case fatality rate across the United States was three deaths per 1,000 cases attributable to measles, or 0.3%. In underdeveloped nations with high rates of malnutrition and poor healthcare, fatality rates have been as high as 28%.[35] In immunocompromised persons (e.g., people with AIDS) the fatality rate is approximately 30%.[36] Even in previously healthy children, measles can cause serious illness requiring hospitalization. One out of every 1,000 measles cases progresses to acute encephalitis, which often results in permanent brain damage. One or two out of every 1,000 children who become infected with measles will die from respiratory and neurological complications.32

In addition to the inaccurate facts and misunderstandings of basic scientific fundamentals, the author concludes her letter with the induction of fear-mongering and hysteria by invoking eugenics, compulsory sterilizations, the Nuremberg code and, of course, Hitler. The author cries “informed consent,” a rebranded anti-vax label, but without factual, unbiased information, one will never actually be “informed.”

[1] Fine, P.; Eames, K.; Heymann, D. L. (1 April 2011). ""Herd immunity": A rough guide". Clinical Infectious Diseases. 52 (7): 911–16.

[2] Hinman, A. R.; Orenstein, W. A.; Papania, M. J. (1 May 2004). "Evolution of measles elimination strategies in the United States". The Journal of Infectious Diseases. 189 (Suppl 1): S17–22.

[3] Hedrich AW. Estimates of the child population susceptible to measles, 1900-1930. Am. J. Hyg. 17:613-630.

[4] Oxford Journals. Monthly Estimates of the Child Population “Susceptible” to Measles, 1900-1931. Baltimore, MD. Am. J. Epidemiol. 17(3):613-636.

[5] Garnett, G. P. (1 February 2005). "Role of Herd Immunity in Determining the Effect of Vaccines against Sexually Transmitted Disease". The Journal of Infectious Diseases. 191 (Suppl 1): S97–106.

[6] Quadri-Sheriff, M.; Hendrix, K. S.; Downs, S. M.; Sturm, L. A.; Zimet, G. D.; Finnell, S. M. (September 2012). "The role of herd immunity in parents' decision to vaccinate children: a systematic review". Pediatrics. 130 (3): 522–30.

[7] Dubé, E.; Laberge, C.; Guay, M.; Bramadat, P.; Roy, R.; Bettinger, J. (August 2013). "Vaccine hesitancy: an overview". Human Vaccines & Immunotherapeutics. 9 (8): 1763–73.

[8] Ropeik, D. (August 2013). "How society should respond to the risk of vaccine rejection". Human Vaccines & Immunotherapeutics. 9 (8): 1815–18.

[9] Esposito, S; Bosis, S; Morlacchi, L; Baggi, E; Sabatini, C; Principi, N (2012). "Can infants be protected by means of maternal vaccination?". Clinical Microbiology and Infection. 18 Suppl 5: 85–92.

[10] Rakel, D.; Rakel, R. E. (2015). Textbook of Family Medicine. Elsevier Health Sciences. pp. 99, 187. ISBN 978-0323313087.

[11] Cesaro, S.; Giacchino, M.; Fioredda, F.; Barone, A.; Battisti, L.; Bezzio, S.; Frenos, S.; De Santis, R.; Livadiotti, S.; Marinello, S.; Zanazzo, A. G.; Caselli, D. (2014). "Guidelines on vaccinations in paediatric haematology and oncology patients". Biomed Res. Int. 2014: 1–10.

[12] Munoz, F. M. (2013). "Maternal immunization: An update for pediatricians". Pediatric Annals. 42 (8): 153–58.

[13] "Herd Immunity". Oxford Vaccine Group, University of Oxford. Retrieved 12 December 2017.

[14] Maglione, M. A.; Das, L; Raaen, L; Smith, A; Chari, R; Newberry, S; Shanman, R; Perry, T; Goetz, M. B.; Gidengil, C (2014). "Safety of vaccines used for routine immunization of U.S. Children: A systematic review". Pediatrics. 134 (2): 325–37.

[15] Demicheli, V; Rivetti, A; Debalini, M. G.; Di Pietrantonj, C (2012). "Vaccines for measles, mumps and rubella in children". Cochrane Database of Systematic Reviews. The Cochrane Database of Systematic Reviews. 2. pp. CD004407.

[16] Pommerville, J. C. (2 December 2014). Fundamentals of Microbiology: Body Systems Edition. Jones & Bartlett Publishers. pp. 559–63.

[17] If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities (Information for parents). https://www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/not-vacc-risks-color-office.pdf. Retrieved 12 Apr 2019.

[18] Vaccine Rejection and Hesitancy: A Review and Call to Action, Open Forum Infect Dis. 2017 Summer; 4(3): Jul 18 2017.

[19] Anti-vaccine activists, Web 2.0, and the postmodern paradigm--an overview of tactics and tropes used online by the anti-vaccination movement. Vaccine. 2012 May 28;30(25):3778-89.

[20] "Can vaccines cause or spread diseases?". Northern Rivers Vaccination Supporters. Retrieved 2018-04-29.

[21] Hall, C. B; Douglas Jr, R. G; Geiman, J. M; Meagher, M. P (1979). "Viral shedding patterns of children with influenza B infection". The Journal of Infectious Diseases. 140 (4): 610–3.

[22] https://www.sciencemag.org/news/2018/03/why-so-many-college-students-are-coming-down-mumps.

[23] Gardiner, W. T. (2007). "Otitis Media in Measles". The Journal of Laryngology & Otology. 39 (11): 614–17.

[24] Fisher DL, Defres S, Solomon T (2014). "Measles-induced encephalitis". QJM. 108 (3): 177–82.

[25] Anlar B (2013). "Subacute sclerosing panencephalitis and chronic viral encephalitis". Pediatric Neurology Part II. Handbook of Clinical Neurology. 112. pp. 1183–89.

[26] Semba RD, Bloem MW (March 2004). "Measles blindness". Survey of Ophthalmology. 49 (2): 243–55.

[27] Gupta, Piyush; Menon, P. S. N.; Ramji, Siddarth; Lodha, Rakesh (2015). PG Textbook of Pediatrics: Volume 2: Infections and Systemic Disorders. JP Medical Ltd. p. 1158. ISBN 9789351529552.

[28] Griffin, DE (July 2010). "Measles virus-induced suppression of immune responses". Immunological Reviews. 236: 176–89.

[29] Rota, Paul A.; Moss, William J.; Takeda, Makoto; de Swart, Rik L.; Thompson, Kimberly M.; Goodson, James L. (14 July 2016). "Measles". Nature Reviews Disease Primers. 2: 16049.

[30] Ellison, J.B (1931). "Pneumonia in Measles". 1931 Archives of Disease in Childhood. 6 (31): 37–52.

[31] Chen S.S.P. (February 22, 2018). Measles (Report). Medscape. Archived from the original on September 25, 2011.

[32] "Measles | For Healthcare Professionals". www.cdc.gov. Archived from the original on 23 October 2016. Retrieved 22 October 2016.

[33] National Institutes of Health Office of Dietary Supplements (2013). "Vitamin A". U.S. Department of Health & Human Services. Archived from the original on 11 March 2015. Retrieved 11 March 2015.

[34] Sabella C (2010). "Measles: Not just a childhood rash". Cleveland Clinic Journal of Medicine. 77 (3): 207–13.

[35] Perry RT, Halsey NA (May 1, 2004). "The Clinical Significance of Measles: A Review". The Journal of Infectious Diseases. 189 (S1): S4–16.

[36] Sension MG, Quinn TC, Markowitz LE, Linnan MJ, Jones TS, Francis HL, Nzilambi N, Duma MN, Ryder RW (1988). "Measles in hospitalized African children with human immunodeficiency virus". American Journal of Diseases of Children. 142 (12): 1271–72.