Measles and the Rise of Vaccine Preventable Diseases

Paul Sax: [00:00:13] Hi everyone. This is Dr. Paul Sax. I'm editor in chief of Clinical Infectious Diseases. And welcome to the Let's Talk ID podcast. Today we're joined by Dr. Adam Ratner. He's professor of pediatrics and microbiology at NYU. And he's also director of the Division of Pediatric Infectious Diseases at Hassenfeld Children's Hospital and Bellevue Hospital Center. He's just written a book called, "Booster Shots The Urgent Lessons of Measles and the Uncertain Future of Children's Health." He has kindly agreed to chat with us today. I will say at the outset, though, these are his opinions and not those of his institutions. Adam, welcome.

Adam Ratner: [00:00:51] Great to be here. Thanks so much for having me.

Paul Sax: [00:00:54] So, so tell us about yourself. What is the Dr. Adam Ratner story?

Adam Ratner: [00:00:58] I grew up in a family of doctors. My mother trained as a pediatrician and then decided she wanted to do critical care type work. And the way you did that at the time was to do an anesthesia residency, and she left pediatrics to do that and never came back. She ended up as a cardiac anesthesiologist and very happy doing it. My stepfather was a cardiac surgeon, and so I grew up in a house where I was steeped in the rhythm and the language of academic medicine from a very early age. And in my early teens, it was the early to mid 1980s. So it was the earliest days of HIV. This was, to my developing teenage brain, simultaneously the most interesting and the most frightening thing I had ever encountered, and that, I think, never left me. And just the idea of the power and the in some ways, the beauty of infectious diseases stayed with me. When I went to medical school, the goal was to be an ID doctor. I found my people on an adult ID rotation and I just, I loved the pace and everything about ID, but then I found my patients and, and their families on a peds ID rotation, and I just, I love working with families and I love both treating kids but also the prevention side, which is a lot of what I focus on now.

Paul Sax: [00:02:24] Okay. Well, now I'm going to ask you about the book. Deciding to write a book is a big decision. What made you decide to do it?

Adam Ratner: [00:02:30] I had an interesting experience, to put it mildly, during the 2018 2019 measles outbreak in New York City, where I found myself taking care of a disease that, in my mind, I had filed under solved problems. I knew about measles. I had a lecture on measles in medical school. I had seen a handful of cases as an ID fellow, you know, a returned traveler, things like that. But now I was seeing 4 or 5 cases of measles a day. We had 650 cases in the city during that outbreak. And just the idea that you could move backwards that quickly and be dealing with a disease that no one should have to be dealing with like that just really stuck with me. I said, this is a story that is interesting and for a wide variety of reasons, is beyond just the story of measles. So I was kicking around the idea of a non-fiction book about measles, and I talked to a lot of people about it, and a lot of people said, why do you want to write a book about measles? And then Covid happened, and it was a little bit of an easier story to tell at the beginning of Covid, how measles was a warning sign. And measles, you know, sort of foreshadowed some of what we were dealing with then. And I had an easier time getting interest in the story at that point.

Paul Sax: [00:04:05] Yeah, I mean, the book really does focus on measles, which is fascinating book. And thank you for sharing with me a copy. Why is understanding this particular infection so crucial to dealing with vaccine preventable diseases today?

Adam Ratner: [00:04:19] Yeah, so the book is about measles, but it is about more than just measles. Measles, as the audience for this podcast likely knows, for the most part, is the most contagious disease that we know of. More contagious than flu. More contagious than Covid. More contagious than Ebola. It's also this eminently vaccine preventable disease. We've had a fantastic live attenuated vaccine since the early 1960s. And so it is something that when we are acting together and doing the right thing, we don't have to deal with. And throughout history, before the vaccine, it has disproportionately caused severe disease among populations that are dealing with poverty and crowding and war and colonialism. It is mild in most kids in places where it's endemic, especially in high income countries. And so it has been, over time, just systematically underestimated in its importance. And as a cause of disease. You even think about the word measly, right? As something that's small or insignificant. And so for for all of these reasons, I think the surges in measles that we've seen in recent years, and I date that to before Covid and certainly since Covid are a general probe kind of for the health of our public health systems, they for how we deliver public health messages, for what vaccine trust and acceptance looks like, all sorts of other things. We see measles first because it's so very contagious, but it's followed by other vaccine preventable diseases and by other public health disasters, and it is this I now appreciate this bright red warning sign that we as a population, as a general population, and as as physicians and public health folks that we don't necessarily pay enough attention to.

Paul Sax: [00:06:14] Well, very well said. I mean, I thought it was fascinating to read your book, how the some of the earliest descriptions about poverty and malnutrition being risk factors for severe outcomes of infectious diseases came from observations of measles. Really, really interesting. So now you mentioned one measles outbreak already, which is the one in New York City that you dealt with. You want to comment any further about that one or any others that you want to mention that have occurred in the recent past?

Adam Ratner: [00:06:41] Sure. I think there are tons of interesting measles outbreaks, believe it or not. You know, they're not all the same. I'll focus on two that are both in the post elimination period. So we eliminated measles from the US in 2000. And that's elimination as opposed to eradication. The only human disease we've eradicated is smallpox. Measles is geographically eliminated, but we still have to vaccinate. We still worry about imported cases. The first one is the Disneyland outbreak in 2015. It started in late 2014. This was interesting for a couple of reasons. So you had a lot of travelers to the Disneyland park in California and also park workers getting sick with measles. But then there were multiple generations of spread in the community after that, you know, initial acquisition in the park and then and then spread in the community. And what that uncovered was these incredibly high rates of non-medical exemptions and under vaccination in kindergartens in California. So if you looked at California as a state and even at most counties as a whole, the vaccination rates were okay. But there were these schools where a quarter of kids were vaccinated.

Paul Sax: [00:07:57] Wow.

Adam Ratner: [00:07:58] Right. And that that just flipped a switch for me that that was like, oh, like fine-scale epi ends up being really important when you're thinking about vaccine preventable diseases. You know, those under-vaccinated areas were clustered in rich populations, wealthy populations and in alternative schools, which is different from, you know, Pre-elimination the places that we really worried about were underserved populations where it was hard to get vaccine in. And this was completely different. The backlash against the outbreak was pretty, was pretty impressive. And people were there was a lot of pro-vaccine messaging. And Richard Pan, who was a state senator and who is, I'm proud to say, a pediatrician, really pushed to get elimination of non-medical exemptions in California. And that helped bring vaccine levels back up. And that, you know, emphasized to me the importance of policy solutions. And so there was a lot-

Paul Sax: [00:08:58] It was a success.

Adam Ratner: [00:08:59] Yeah, there was a lot packed into that. Of course, there's now tremendous pushback against those kinds of regulations. But it was, it was a really informative thing.

Paul Sax: [00:09:10] Yeah. But no, I mean, it was really interesting also because it alerted me to the fact that that vaccine hesitancy sort of spans the political spectrum. That people who are otherwise extremely intelligent and well-educated could have this view, which I would think is associated with ignorance. But, you know, there you go. People on the left, people on the right, people in the middle. It doesn't really matter. Any other outbreak?

Adam Ratner: [00:09:35] Yeah. I mean, I'll just comment in a little more detail on 2018 2019 outbreak in in New York City. Because it's close to my heart. It started with an imported case as most of these do. And then measles just tore through these majority Orthodox Jewish populations in both Brooklyn and Rockland County, which is north of New York City. It was the same kind of thing with the overall state or city rates of vaccination among kindergartners and then much lower rates in the populations. But the other thing that came out during this is that, I think it was a different kind of vaccine hesitancy. It was based in large part in this long-standing distrust in public health messaging, and there were fights between the orthodox populations and the New York City Department of Health over things that had nothing to do with vaccination but that went back many years, and that, I think, contributed. And then the only thing that really seemed to work in terms of combating vaccine hesitancy in that outbreak was this really sort of hyper local, culturally competent messaging where there was this group of orthodox nurses that went from literally from like living room to living room and sat with people and showed them data and showed them how to read a study. And it's something that does not scale in any way, but is probably the only thing that's effective.

Paul Sax: [00:11:02] Now, you had your own personal experience with this outbreak. Why don't you share that with us? You know, getting protested.

Adam Ratner: [00:11:10] Sure. It was remarkable. First of all, just as a clinical ID doctor, it was fascinating. We saw a tremendous number of kids. Some of them were very sick. We had ICU admissions. I'm happy and proud to say that nobody died. But it was - these kids were sick. And, you know, again, like I knew from medical school, from fellowship, you know, you read about measles, you're like, yes, people can get sick from measles. And then you see it. And these are kids who are miserable. That was interesting and important to me. And I think just seeing the animosity between the population and the public health messaging, people who are, people like me and, and my colleagues and who are trying to protect kids. And there was a lot of pushback. And that was in retrospect, that was foreshadowing. But I didn't realize that at the time because we were right around the corner from Covid. It was interesting.

Paul Sax: [00:12:10] But that brings us to Covid, which of course, I have to bring up. It both gave life to your book, but also has made this even more challenging because it's fueled broader vaccine skepticism. So two really questions for you as a pediatrician. And, you know, full disclosure, I'm married to a pediatrician and she has her own opinions on this, I think. Do you think we oversold the Covid vaccine to children? And the second question is, how do you see that the Covid vaccine in children and its impact on childhood vaccination rates for other diseases moving forward?

Adam Ratner: [00:12:43] The short answer is no. I don't think we oversold the Covid vaccine to children. I took care of kids with Covid throughout the pandemic and like just to say up front, of course you would rather be a child with Covid in general. You would rather be a child with Covid than an 80-year-old with Covid so stipulated. And yet, even though most kids did fine, we had kids in the ICU with respiratory failure. We had immunocompromised and neurologically impaired kids with severe illness. We had 1000 kids in the United States who died of Covid. That's a disease worth vaccinating against, even if that's all the information you have. So vaccines are safe in kids and they work. They prevent severe disease. Do they prevent, you know, all infections in kids? No, of course not. And they don't in adults either. But the risk benefit clearly favors vaccinating kids against Covid.

Paul Sax: [00:13:36] Just let me stop you there. Do you think it's still favors it now that there's broad population immunity? Or is that only early in the phase of the pandemic?

Adam Ratner: [00:13:45] No, I do think that because I think that Covid is still certainly circulating and this has been a lighter Covid year. But every year we have a new birth cohort that is not born with the same level of immunity that the people in the surrounding population have. And I think you vaccinate against things because there are rare, severe outcomes. And the you know, the second piece of this is that we vaccinate kids as a component of protecting the larger population. And that's not unique to Covid, but a quarter of the population in the United States is children. And you don't get anywhere near effective herd immunity without protecting kids. Peri Class and I wrote a New England Journal perspective piece about this or, you know, early during the vaccine rollout. And we got pushback about it. But it's I do not see this as a controversial take.

Paul Sax: [00:14:40] Okay, good. I'm glad to hear your perspective. But do you think that that the recommendations for the Covid vaccine or Covid in general has had an impact on childhood vaccination rates? And what do you expect moving forward?

Adam Ratner: [00:14:53] Oh, without a doubt. I think there are two components of that. I think the first is just generally around public health communications and that was it was difficult. You were there. I was there like people I think early on did an incredible job of reporting what they were seeing, trying to figure out how transmission worked, trying to figure out infection control and what the disease looked like. You know, we knew it was a respiratory disease. We did not know at the beginning that there was something like multisystem inflammatory disease in children. Like there are there are all of these things that we didn't know a priori. I remember a point really early in the pandemic. It was probably late March or so in New York City, where we had, you know, there are always febrile infants coming into the emergency room for workups. And that's fine. And I got the question, should we be testing these kids for Covid? And we tested some of them, and we had like 4 or 5 in a row who were positive. And we were like, oh no. We didn't say no [laughs] but it's a yeah, a family podcast. Um, and so, you know, just because from an IPC point of view, this was a nightmare. Like we had not considered that children without respiratory symptoms were coming in with SARS-CoV-2 infection and could be infectious, and so we dealt with things differently after that. We had a CID publication about that. And so thank you for that.

Paul Sax: [00:16:16] [laughs]

Adam Ratner: [00:16:17] But on a, you know, on a local level, on a national level, on an international level, we were figuring things out as we went along. And the problem was that there were all of these families out there who were also trying to figure things out day by day, and they were relying on our advice.

Adam Ratner: [00:16:32] And, you know, they were trying to figure out their jobs and school for their kids and how to shop for groceries. And so it was frustrating when guidance changed. I think it mostly changed not because of malice, but because we were literally figuring things out day by day. That fueled, I think, a lot of disgust and exasperation with public health voices. And then there was, you know, that was accentuated by people pushing bad information. And there was pushback against the Covid vaccines before the vaccines were ever licensed or authorized. And then when they weren't 100% perfect, there was more predictable backlash that pivoted, which I think was part of the anti-vaccine plan all along, that pivoted to childhood vaccines that were not Covid and to vaccine mandates. And so I'm extremely concerned about this going forward. I mean, we're in a situation now where, you know, the trends are bad, like the MMR vaccination rate in kindergartners is like under 93%. You need 95% for effective herd immunity against measles. And it's dropping. And some areas are much lower. Exemptions are growing. And you know parents are opting out. And it's a respiratory for a vaccine preventable disease nightmare. I mentioned my mom earlier. So she she took care of, you know, a million kids with invasive Haemophilus influenzae type b disease during her training. I went through 30 years of my career without seeing invasive Hib and in the last three years have seen three cases. So it is not just Covid and it's not just measles.

Paul Sax: [00:18:14] Yeah. No, I mean, you know, my wife has shared the same experience. She saw the disappearance of invasive Hib, she saw the disappearance of rotavirus. She saw the disappearance of invasive pneumococcal disease. I mean, one after the other. I mean, it's just extraordinary and severe. Varicella also is much, much less common than it used to be. So all those are tremendous advances. It's not the same with Covid 19. And I think that's really what you're getting at, is that you don't have that same degree of community effectiveness. I want to get to something you mentioned in the book, which is these school vaccine mandates and a Mississippi ruling in particular, what happened, because this is in the last couple of years, right?

Adam Ratner: [00:18:59] Yeah. So school mandates are absolutely crucial to maintaining high pediatric vaccination rates. This has been shown again and again. They are a tool that works. They push families to prioritize something at a particular time that they might not otherwise prioritize. Right then it might not bubble to the top of their list. All 50 states have school vaccine mandates, and they have since the 1980s. They're variably enforced, and some states have really permissive opt out policies. And that's what happens, what you get with that is California before the Disneyland outbreak. Mississippi, interestingly, because it's a state that I think struggles with a lot of of indicators of child health, and that's in large part because a large percentage of children in Mississippi live in poverty, was a shining star for vaccination, vaccination rates near the top of all states for many years. And that's because they had early on eliminated non-medical exemptions. So all states allow for medical exemptions, of course, if you have a severe allergy to a component of a vaccine or something, you should not be mandated to get that vaccine. That's clear. But they did not allow for religious or personal belief exemptions. That stood up for a long time. And then recently, there was a lawsuit from an anti-vaccine group run by people who are peripherally connected to RFK. And I don't know about RFK's direct, you know, involvement in that. And the rule was struck down. And so now religious exemptions are allowed in Mississippi. It's still early. That ruling came in 2023. And I don't actually know the effective date of that. But I know at this point people are allowed to get religious exemptions. I think the overall impact of on vaccination rates there can really only go in one direction.

Paul Sax: [00:20:47] Yeah, yeah, that's really unfortunate. I actually had the honor of interviewing Dr. Samuel Katz, who, as you know, is one of the pioneers of the measles vaccine, and he stressed the importance of the vaccine mandates for school attendance and how it has made the United States in many ways better off than Europe in prevention of measles outbreaks.

Adam Ratner: [00:21:11] Yeah, I mean, I think, I think the idea of vaccine mandates grates on some people. Like, I think it is it feels like an anti-American kind of thing where you're taking choice away. But really, what it is prioritizing both the health of the kids who are getting vaccinated and the health of the of the collective, of the kids and the adults around them. And it is like other things have been tried, strong recommendations have been tried. And the thing that works is tying vaccine mandates to school attendance.

Paul Sax: [00:21:46] Do you have an opinion about what the government, media and we healthcare professionals should do? I mean, this is a very broad question. You and I are both infectious disease doctors and we are strong vaccine advocates. Any advice for us?

Adam Ratner: [00:22:00] I mean, this is really hard. Like, we all, we all need to pull in the same direction. You know, government and media and us that like that's the most crucial thing. And I mean, one of the most striking things to me when I was researching the book is just how long it took us to go from having a measles vaccine to effective use of the vaccine and elimination of measles in the US. And that's because when it was first licensed, there was no plan for paying for it. And so, you know, families had had trouble affording it and it worsened disparities. And then there were these, like tepid and confusing recommendations at the beginning, because two vaccines were licensed, a killed vaccine and a live attenuated. And there was a preference for the live attenuated. But the killed had fewer side effects. And so parents wanted to opt for the killed. And there were competing governmental interests where like they would push the measles vaccine for a while. And then the rubella vaccine came out and they would redirect funds to the rubella vaccine and all of these other things. It was only once you had a coordinated effort and governmental will in the form of school mandates and financing for vaccination through the vaccines for children program. Like you needed all of those things to get us to a place where we had effective population immunity. And if any of those things falter, as the government piece is doing and is about to do in a much bigger way, I think it's a recipe for a much worse situation.

Paul Sax: [00:23:32] Yeah, yeah. So that that actually, you know, I want to say that if you could communicate one thing from your book for policymakers or the public, what would it be? Would it be that or what is the sort of a key message?

Adam Ratner: [00:23:46] Yeah, it would be this. Public health gains are fragile. Like we have made incredible progress in the last century in how long people live in, whether children survive childhood in all sorts of things. And a lot of that is vaccine driven. But we need continued vigilance. We need to continue to use the tools that we have to say nothing of inventing new tools and having innovation like that's all important. But if we want to even just stay where we are at this incredible point in human history, where we live longer and kids don't die in childhood at nearly the rates that they used to, we have to use those tools.

Paul Sax: [00:24:25] Good message. And any, you know, a single myth or misconception about measles, one that you wish people understood and would go away?

Adam Ratner: [00:24:32] I think the most important myth about measles that's out there is that it's a mild childhood disease. That is true for a subset of the population, on a subset of the Earth. And it is not true. There are rare, severe cases even in the richest families and the richest countries. But that is not how much of the Earth experiences measles. And I think it's a that is a driver of this centuries long systematic underestimation of how important a disease it is.

Paul Sax: [00:25:06] Well, one thing I always mention when talking about the benefits of childhood vaccines is that if you have millions of children getting infected, all it takes is a few to have a dramatic effect on healthy years of life lost. Because we're talking about humans who otherwise would live decades.

Adam Ratner: [00:25:25] Right.

Paul Sax: [00:25:25] And so a death or a permanent disability has an excess impact. All right. So now comes the fun part. Ready?

Adam Ratner: [00:25:34] I'm ready.

Paul Sax: [00:25:35] Quick answers. Favorite antibiotic?

Adam Ratner: [00:25:38] Oh, the cool people, I think say doxycycline. The true pediatricians say amoxicillin. I say meropenem.

Paul Sax: [00:25:43] Oh my goodness. Going big guns. Favorite ID diagnostic test?

Adam Ratner: [00:25:50] I am an old-fashioned guy. There is nothing I like [more than] a good old culture. So either a blood culture or if you've got a nice positive CSF, that's fine too.

Paul Sax: [00:25:58] Okay, how about your dog? I know you have a dog. What does your dog do?

Adam Ratner: [00:26:02] My dog is amazing. Her name is Lira. She is a very good girl. She is, we think, a beagle mix. And her stupid pet trick is she communicates with cats better than she communicates with other dogs. She just loves cats.

Paul Sax: [00:26:16] It's very unusual. All right. And favorite thing to do in your free time?

Adam Ratner: [00:26:20] Walking Lira in the park. My wife and I say that this is the only way we're capable of interacting with other adults outside of work. So that’s the thing.

Paul Sax: [00:26:29] Well, thank you very much. I have had the distinct pleasure of chatting with Dr. Adam Ratner. He's the head of pediatric infectious disease at NYU slash Bellevue Hassenfeld Children's Hospital, and he was talking about his latest book, "Booster Shots The Urgent Lesson of Measles and the Uncertain Future of Children's Health." Thanks so much for joining us, Adam.

Adam Ratner: [00:26:48] Thanks so much. This was great.