By KIRK JOHNSON
Published: May 12, 2012
MOUNT VERNON, Wash. — Whooping cough, or pertussis,
a highly infectious respiratory disease once considered doomed by science, has
struck Washington State this spring with a severity that health officials say
could surpass the toll of any year since the 1940s, before a vaccine went into
wide use.
Although no deaths have been reported so far this
year, the state has declared an epidemic and public health officials say the
numbers are staggering: 1,284 cases through early May, the most in at least
three decades and 10 times last year’s total at this time, 128.
The response
to the epidemic has been hampered by the recession, which has left state and
local health departments on the front lines of defense weakened by years of
sustained budget cuts.
Here in
Skagit County, about an hour’s drive north of Seattle — the hardest-hit corner
of the state, based on pertussis cases per capita — the local Public Health
Department has half the staff it did in 2008. Preventive care programs,
intended to keep people healthy, are mostly gone.
The county’s
top medical officer, Dr. Howard Leibrand, who is also a full-time emergency
room physician, said that in the crushing triage of a combined health crisis
and budget crisis, he had gone so far as to urge local physicians to stop
testing patients to confirm a whooping cough diagnosis.
If the signs
are there, he said — especially a persistent, deep cough and indication of
contact with a confirmed victim — doctors should simply treat patients with
antibiotics. The pertussis test can cost up to $400 and delay treatment by
days. About 14.6 percent of Skagit County residents have no health insurance,
according to a state study conducted last year, up from 11.6 percent in 2008.
“There has
been half a million dollars spent on testing in this county,” Dr. Leibrand said
late last week. “Do you know how much vaccination you can buy for half a
million dollars?” And testing, he added, benefits only the epidemiologists, not
the patients. “It’s an outrageous way to spend your health care dollar.”
State health
officials estimate that because of incomplete testing and the assumption that
many people with mild cases are not seeking medical treatment, perhaps as few
as one in five pertussis cases is being recorded and tracked, suggesting that
the outbreak is far more widespread than the numbers indicate.
Pertussis
was once a dreaded disease of childhood — killing 5,000 to 10,000 Americans a
year from the 1920s through the 1940s — but is now a risk mostly to infants, to
whom it is fatal in about 1 percent of cases. Most of the victims in
Washington, as in previous outbreaks in other states, are between 8 and 12.
“It’s the
largest epidemic I’ve ever seen,” said Becky Neff, the only registered nurse in
the 3,700-student Burlington-Edison School District, in Skagit County. Ms. Neff
said she had seen 142 suspected and confirmed cases, or about 3.8 percent of
the student population from kindergarten through 12th grade.
But with
only two nurses processing the disease reports she sends over to the county,
down from five a few years ago, Ms. Neff said she had stopped even trying to
ask for confirmation.
“They don’t have
time to call and say who’s positive and who’s negative,” she said.
The
pertussis vaccine is commonly given in childhood, and many states require it
for children of school age. But Washington State, according to a federal study
last year of kindergarten-age children, had the highest percentage of parents
in the nation who voluntarily exempted their children from one or more
vaccines, out of fear of side effects or for philosophical reasons.
So-called
underimmunization — in which children do not get the full series of
vaccinations — could also be a factor in compounding the outbreak, said Mary
Selecky, Washington State’s secretary of health.
Last year,
the Washington Legislature passed a law requiring parents to prove that they
had consulted a physician before declining vaccinations for their children.
“We had the
easiest opt-out law in the nation until last year, so what we also had was the
highest percent of parents opting out,” Ms. Selecky said.
Officials at
the federal Centers for Disease Control and Prevention, which sent three
epidemiologist investigators to Washington last week, said the number of
pertussis cases had been rising gradually nationwide for several decades, with
periodic regional outbreaks. In 2010, California had its worst bout with
pertussis in decades.
Dr. Thomas
Clark, an epidemiologist at the C.D.C., said changes in the vaccine may be
partly responsible. The formula was altered beginning in the early 1990s to
reduce side effects, which means that its immunizing effects do not last as
long, he said.
Most of the
victims in the Washington outbreak and other recent ones received their early
childhood vaccinations, Dr. Clark said. An early immunization, even if it does
not keep a patient from getting the illness, generally produces a milder case,
he said, since the victim would still have some residual resistance.
Ms. Selecky
said immunizations were meant to protect not only individuals but also the
broader population: the so-called herd immunity threshold. If a large enough
segment of the population is unprotected from a disease — generally considered
5 percent to 15 percent, depending on the disease — even people with some
degree of immunity through vaccination can have an elevated risk, she said.
Before the
law was passed, Washington’s vaccination exemption rate was more than 6
percent.
But the
drumbeat of publicity about the pertussis outbreak could be changing some
minds.
Mary Ann
Mercer, 74, a retired schoolteacher, went to Skagit County’s walk-in clinic on
Thursday morning for a vaccination after hearing news reports. She never had
whooping cough as a child, she said, and never thought of it much until
recently.
“It’s just
precautionary,” she said after receiving her shot.
Her husband,
Roger Mercer, who ran a local Blue Cross insurance plan before his retirement,
sat anchored to his chair in the waiting area.
“I’m a
coward,” he said.