Rare Hib disease increases in Minnesota

Is the anti-vaccine movement to blame?

Julieanna's brother Chris touched Julie's hand. "JuJu," he said. And the baby grinned.

The worst was over, and slowly, Julieanna began to recover. As a result of the illness, she'd forgotten everything she'd ever learned: how to swallow, crawl, walk, and talk. Her days filled up with therapy appointments. The doctors did more tests and discovered that she had hypogammaglobulinemia, a rare immune deficiency disorder. Julieanna's body lacked four antibodies needed to fight infectious diseases, the immunologist explained. Even though she'd been vaccinated, the immune deficiency made her vulnerable to contracting Hib. Julieanna was likely to face recurrent infections for the rest of her life.

On February 15, three weeks after she'd been rushed to Children's Hospital in Minneapolis, Julieanna finally went home to Watertown. But Flint lay awake each night, tossing in her bed. Julieanna was at risk. Would she survive the next time she got sick?

Julieanna Metcalf
courtesy of Brendalee Flint
Julieanna Metcalf
Brendalee Flint's daughter, Julieanna Metcalf, contracted a rare, life-threatening infectious disease
Erin Carlyle
Brendalee Flint's daughter, Julieanna Metcalf, contracted a rare, life-threatening infectious disease


IN DECEMBER 2007, an investigator conducting a routine safety test at Merck's production headquarters for the Hib vaccine in Pennsylvania saw something that made him pause. A sample taken from the production line showed evidence of being tainted with Bacillus cereus—a bacteria that could cause symptoms of food poisoning. Thousands of children could be at risk for nausea and diarrhea.

On December 11, the company recalled 12 batches of vaccine—a quantity that was supposed to vaccinate the nation's babies against Hib through January 2010. Minnesota doctors began pulling the shots from their shelves. Only one other company manufactured an equivalent product, and it couldn't make enough to fill the gap.

The Centers for Disease Control and the American Academy of Pediatrics quickly stepped in with recommendations: Doctors should give the primary vaccine series to infants younger than seven months, and skip the booster for 12- to 15-month-olds. Complicating the shortage even further, doctors had to remember to give three shots of the replacement vaccine series, whereas Merck's vaccine had included only two injections.

To Lynn Bahta, a pediatric nurse and immunization consultant for the Minnesota Department of Health, the shortage created a predictable equation: Less vaccine meant more children would get sick. In fact, that was exactly what happened. In 2007, about 93.7 percent of children had the infant Hib series before they turned three, and only one child got Hib. But during the Merck shortage in 2008, Bahta and her colleagues discovered, less than half of the state's babies received the full three-series Hib vaccine by the time they were seven months old—and five children got Hib. One of the five children, a seven-month-old, died.

Bahta, one of dozens of healthcare workers investigating the Hib mystery, feared that the five cases were canaries in the coal mine. "In order to contain disease and prevent outbreaks, you need to have immunization rates of around 90 percent or higher," she explains.

Bahta knew that, historically, most Minnesota parents had vaccinated their children, but she also knew that the state's vaccination rates had been inching downward. In 1992, the rate of kindergarteners whose parents were conscientious objectors to vaccinations was 0.2 percent. By 2002, the latest numbers available, 1.27 percent weren't vaccinating. Had the numbers of people not vaccinating their children risen so high that now more kids were contracting Hib? Or had the shortage of the Merck Hib vaccine put more children at risk?

To solve the mystery, Bahta and her colleagues at the state health department investigated each of the Minnesota cases, searching for a common link. Did the families know one another, and had the children contracted the disease from each other? Or did they know someone in common who carried the disease and spread it from one child to the next? No, Bahta and her team found out, the five families lived miles apart in different counties, had never met, and knew no one in common. So were more children carrying Hib this year? No, the health department swabbed the throats of 1,600 kids and found no difference.

In fact, the only places in the country where Hib had gone up were Minnesota and Pennsylvania, where six children got sick and three died. The national rate hadn't changed a bit.

Still, the CDC took the Hib cases as an opportunity to push vaccines. "The increase highlights the need to ensure that all children complete the primary Hib immunization series," one CDC statement read.

In recent years, outbreaks of infectious diseases once thought to be eradicated in the West have popped up in several unvaccinated communities in Minnesota. In 1996, several children belonging to Christ's Household of Faith in St. Paul got the measles. In 2005, a polio outbreak hit an unvaccinated Amish community in central Minnesota.

Outside Minnesota, outbreaks of vaccine-preventable diseases have surged where vaccines are unpopular. Measles tore through unvaccinated communities in California, Arizona, and Washington last year, eventually infecting 127 people in 15 states.

"All you have to do is drop your guard a little bit, and these diseases come back," says Paul Offit, chief of Infectious Diseases and director of the Vaccine Education Center at Children's Hospital of Philadelphia. A prominent vaccine advocate and co-inventor and patent-holder of the rotavirus vaccine, Offit is disturbed by the trend of refusing vaccines. "I used to say this will change when children start to die. Now I'm starting to say, this will change when enough children die."

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