Vaccinations and the Immunocompromised Community

In the United States and around the world, physicians and public health officials are fighting a familiar foe: vaccine-preventable diseases. Illnesses such as measles, hepatitis A, and mumps have seen disturbing upward trends and outbreaks in recent years despite the existence of highly effective vaccines against them. In the absence of vaccination, these diseases can be highly contagious. A single incidence of measles infection can quickly balloon to dozens depending on the locale, population density, cultural practices, and medical infrastructure of the infected patient’s environment. While many vaccine-preventable diseases exert mild symptoms in most adults, they can be deadly for the immunocompromised, infants and elderly.

Currently, Rockland County, New York is experiencing the largest measles outbreak in almost 25 years. In North Carolina, an outbreak of varicella (the chickenpox virus) is ongoing. These outbreaks, like many others, are largely fueled by vaccine hesitancy/delays, exemptions, and refusal (which I will call “non-adherence” for the remainder of this article). This vaccine non-adherence decreases immunity to disease within a community, putting the local residents at an elevated risk for disease spread. Should a vaccine-preventable disease be introduced into this community, the disease can quickly spread and overwhelm the community, potentially leading to a rapid spread throughout neighboring principalities and urbanized areas.

This rapid spread can be observed in countries such as Greece, Italy, Romania, and France, which have seen a resurgence in these diseases because community vaccine coverage has waned.

It has become increasingly apparent that many do not fully appreciate the impact vaccine-preventable diseases can have on our communities. From an economic standpoint, it is estimated that vaccine non-adherence costs the U.S. taxpayers over $7 billion per year, with ~$5.8 billion coming just from flu vaccine refusal. The cost of containment of a measles-infected patient at hospitals can be as high as $122,000, due to the incredibly contagious nature of the virus.

From a humanistic standpoint, infection with the flu virus results in upwards of 700,000 hospitalizations and claims about 12,000 to 56,000 lives per year in the U.S. alone. Measles, which was declared eliminated from the Americas in 2002 (although not eradicated), infected almost 7 million people in 2017 and resulted in over 110,000 fatalities.

So why is it that so many refuse vaccinations, and who ends up paying for that decision?

Skepticism of vaccinations is not a new ideology. The eradication of smallpox in the 20th century was complicated through anti-vaccine groups who used anecdotal observations to draw sweeping conclusions about the smallpox vaccine. More recently, conspiracy theories about a link between vaccines and autism have flooded corners of the internet. This theory primarily traces its inception to a manuscript published in 1998 that implicated a link between the measles, mumps, and rubella vaccines and autistic spectrum disorders.

Independent groups around the globe were not able to reproduce these findings, and it was determined that data falsification and ethical malpractice involving minors occurred, leading to full retraction of the manuscript. However, the lasting damage that it has caused amongst genuinely concerned parents cannot be underestimated. Accordingly, it has been dubbedperhaps the most damaging medical hoax of the last 100 years”. Other reasons for vaccine non-adherence include:

– Government take-over conspiracy theories

– Religious objections to vaccine production and testing procedures

– Fear of needles

– A feeling of ambivalence towards the disease – “It’s just a rash after all”.

This last reason is dangerous for reasons that many may not fully comprehend.

The human immunodeficiency virus (HIV) is the causative agent of AIDS, a medical condition that occurs when the virus has destroyed enough white blood cells to allow for opportunistic pathogens and diseases to overtake the host. HIV was first brought into the human population around the late 19th and early 20th century, and continuous and sustained transmission of the virus gave rise to the worldwide AIDS epidemic. HIV directly infects and attacks a class of white blood cells called T-cells, which are immune cells critical for the proper production of antibodies and regulation of the immune system. Due to the relentless assault on the immune system by the virus, individuals infected with HIV are immunocompromised.

Currently, there are roughly 1.1 million people living with HIV in the U.S.; they are our neighbors, our colleagues, our friends, and our family. One of the most frequent causes of death in the HIV/AIDS community is pneumonia caused by complications with vaccine-preventable diseases such as the flu.

While many HIV+ individuals can and do receive the annual flu vaccine, their immune systems may not able to fight off the viral infection as well as others. To that end, the HIV community can greatly benefit from an environment with a high vaccination rate. By getting a flu shot, you not only are protecting yourself from becoming sick with the flu virus, but you are also limiting the exposure of those around you to the pathogen.

Of course, those living with HIV are not the only individuals in our society who are immunocompromised. Others that can fall under this category include organ transplant recipients, those on certain chemotherapies for cancer treatment, and patients with genetically inherited immunodeficiencies.

Additionally, infants who are still developing their immune systems and the elderly who tend to have less responsive immune systems are more likely to experience complications after contracting vaccine-preventable diseases. Many of us probably know and regularly interact with someone who falls under the broad umbrella of immunocompromised, and when receiving a vaccine, you are protecting them in ways you may not have realized.

While a disease such as measles may be brushed off as “just a rash” by some, it is important to remember that not everyone can fight off these diseases as efficiently as others. There are some very severe complications caused by vaccine-preventable diseases: varicella and measles virus can lead to pneumonia and encephalitis (swelling of the brain); pertussis can lead to broken ribs and convulsions; mumps can lead to deafness and meningitis.

It is also noteworthy that many vaccine-preventable diseases can cause premature birth, fetal developmental impairments, and even stillbirth. Another potential effect of contracting these vaccine-preventable diseases is death. While any one of us can succumb to these illnesses or become permanently disabled, the risk is higher for those who are immunocompromised. Though many who avoid vaccinating themselves and/or their children believe it is the safest choice, the reality is that vaccine non-adherence jeopardizes their own health as well as our community’s vulnerable population.

In summary, vaccines are some of the most thoroughly tested medical interventions that we have. Vaccinations are safe; the diseases they are designed to prevent are not. Vaccine-preventable diseases can be exasperated by pre-existing conditions such as an immunocompromising illness (HIV and genetic disorders) and immunosuppressant drug therapies (organ transplant recipients and certain cancer therapy regiments).

When you and your loved ones receive a vaccine, you are protecting these communities. Misinformation and conspiracy theories regarding vaccines are a danger to public health for these reasons. Whether it is a work colleague living with HIV, a child undergoing chemotherapy, an elderly patient who recently received an organ transplant, or a person sitting next to you on the subway living with a predisposed genetic immunodeficiency, many of us regularly interact with the immunocompromised community.

Keeping yourself and your family vaccinated is imperative to public health; you may not know it, but some people’s lives could literally depend on it.