Whooping Cough’s Comeback Raises Questions

How states’ decisions to not require vaccinations and general budget cuts to public health have impacted the nation’s ability to prevent, track and treat disease outbreaks.
by | August 2012

A century ago, whooping cough spread dread across the country, causing more than 5,000 deaths a year. But after scientists discovered that the pertussis bacteria caused the awful respiratory disease, with its characteristic “whoop” sound, researchers produced an enormously effective vaccine. Then they went a step further and combined that vaccine and the antibodies to diphtheria and tetanus into a single shot (DPT), putting an end to the three diseases that had terrorized kids for decadess.

But by the 1970s, parents were growing increasingly suspicious of the DPT vaccine, particularly that it was causing brain damage, including encephalopathy, a condition that can produce personality changes, tremors and seizures. After a 1982 NBC documentary won an Emmy Award for its tale of children said to be injured by the vaccine, an anti-vaccination epidemic was born, spurred further by a 1998 study that suggested the measles, mumps and rubella vaccine caused autism. (In 2010, that study was retracted by the journal that had published it.)

Today, untold thousands of children have never received these vaccinations. As a result, the dreaded diseases of the 1900s are making a comeback. In May, Washington state public health officials declared a health emergency as whooping cough galloped across the state. In just the first month, the disease infected more than 2,500 Washingtonians, with children ages 10-13 hit especially hard. Other states, including California and Wisconsin, have had outbreaks as well, but in Washington the infection rose to an epidemic.

How could a disease we thought we had licked have spread so fast? Part of the explanation comes from Washington parents who took advantage of a new law allowing them to opt out of vaccinations for their kids. Another part comes as a result of a new DPT vaccine designed in the 1990s to cause fewer side effects, but which declined in effectiveness over time, leaving adults with lower levels of protection.

Perhaps the biggest part of the problem, however, comes from under-investment in public health. Financially strapped states, including Washington, have been struggling to support programs to immunize kids, advertise the benefits of the dreaded shots, track the spread of diseases of all kinds and manage the consequences. Becky Neff, a registered nurse in Skagit County, along the Puget Sound near the Canadian border, told a reporter, “It’s the largest epidemic I’ve ever seen.” How large? No one really knows, she explained, because the county has just two nurses compiling disease reports, compared with five just a few years ago. The nurses who are left “don’t have time to call and say who’s positive and negative.”

The economic downturn has left a trail of debris in its wake, and public health has been especially hard hit. Rhode Island’s free breast and cervical cancer screening programs have been suspended. In Washtenaw County, Mich., budget cuts forced the government to suspend new enrollment in a health coverage program for low-income residents who didn’t qualify for Medicaid. In the last two years, the local public health workforce has dropped 15 percent, according to the National Association of County and City Health Officials.

Public health workers are usually the last noticed of the first responders. The public tends to dismiss them as disease-counters and shot-givers -- until killer tomatoes strike (with a salmonella outbreak in 2008) or anthrax threatens (after the 9/11 terrorist attacks).

This year’s whooping cough outbreak shows how fast disease can spread. The 1918 Spanish flu pandemic, which killed more than 50 million people around the world, showed just how serious that can be. And in today’s super-linked world, any disease anywhere can deposit itself on anyone’s doorstep in just hours. In fact, just one airplane passenger from Hong Kong brought severe acute respiratory syndrome (SARS) to Toronto in 2003. The resulting outbreak virtually shut the city down and killed 44 people.

The Washington whooping cough emergency, fortunately, didn’t rise to that scale. But it does raise two very worrisome points. First, disinvesting in public health now can pose serious consequences down the road. Whether we can accurately count the number of pre-teens struggling with whooping cough might not seem like a big deal, but if we suddenly have to track and manage the spread of a SARS-like disease, the lack of capacity would aggravate a grade-A crisis.

Second, if nervous parents push opt-out provisions on state policymakers, and if individual states loosen the requirements for vaccinations and other public health strategies, the individual decisions can quickly create far broader ripples. Many public health programs rely on the inelegantly named “herd” strategy. If almost everyone is immunized, a single whooping cough victim can easily be isolated. If large numbers of kids haven’t been vaccinated, or if vaccines for their parents begin to wear off, one cough can quickly spread across the population.

Individual parents’ decisions about vaccinating their kids might seem limited to their own families, but nothing could be further from the truth. It’s no exaggeration to say that such parental decisions, sanctioned by individual states and repeated many times over, can have national consequences. Couple that with budget cuts at the heart of the nation’s public health capacity. We see evidence everywhere of the huge consequences of the Great Recession, but Washington’s whooping cough outbreak shows an important break in our first-response lines of defense.

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