When Immunity Fails: The Whooping Cough Epidemic

This KPBS documentary already has an English transcript, so translating in other languages should be a breeze!

JOANNE FARYON: Hello, Iím Joanne Faryon.
Welcome to tonightís special, When Immunity

Fails: The Whooping Cough Epidemic. Weíll
explore the worst whooping cough outbreak

in California in more than 60 years. Just
why is a disease that was nearly extinct thirty

years ago, finding its way back not just in
this state, but in other parts of the country

as well? What we learned may surprise you.
There are serious questions about how well

the vaccine to prevent the disease works;
questions government health officials have

been slow to even ask. KPBS teamed up with
the Watchdog Institute, an investigative journalism

center at San Diego State University, and
Radio Netherlands Worldwide to tell this story.

A story that took us across California and
overseas to Amsterdam. But first, we begin

in a delivery room in a San Diego hospital,
where a mother has just given birth to her

third son.

[ baby crying ]

Matthew Jacob Bryce was born Oct 11, 2010.
A healthy baby boy, the third boy for Cindy

and Marlon Bryce. Matthew started showing
signs of a cold when he was just two weeks

old. The Bryce family knew something was wrong.

MARLON BRYCE: So it just seemed like this
cold it was just affecting his breathing.

FARYON: The family was aware of the whooping
cough epidemic in California, from news reports

REPORTER: State health officials say more
than 6,400 cases of whooping cough have been

reported this year.

FARYON: And their pediatrician.

BRYCE: There wasnít any whooping or they
always say there is a whooping or a cough,

he didnít have a cough or anything it was
just that there was a cold.

FARYON: Matthewís doctor suspected it could
be whooping cough, also known as pertussis.

She took a nasal swab and sent it to the lab.
She also started Matthew on antibiotics. Six

days later, with Matthew just 23 days old,
Cindy Bryce got a phone call from the California

Department of Health. The diagnosis was whooping
cough.

M. BRYCE: The moment I heard it I just immediately
started thinking the worst because you have

heard the news about the babies that have
passed away.

FARYON: From January to October this year,
10 newborns in California died from whooping

cough, two in San Diego County. More than
7,000 children and adults got sick from the

disease - the highest number in the state
in more than 60 years. Just how did Matthew

and so many others come down with a disease
that is supposed to be preventable with a

vaccine? Tonight weíll raise questions about
the effectiveness of that vaccine. A four-month

investigation by KPBS and the Watchdog Institute,
found many people who have been diagnosed

with whooping cough were immunized. We also
show how government data on the number of

people diagnosed with whooping cough lacks
timeliness and is often inconsistent, begging

the question: just who is keeping track of
this epidemic?

Weíll show you how some of the experts who
influence vaccine policy are financially tied

to vaccine companies. And, weíll follow the
Bryce family as they struggle with their sonís

diagnosis, and the setbacks in his recovery.
Whooping cough, violent cough, the hundred-day

cough; all names for pertussis.

DR. JAMES CHERRY: What causes the cough actually
we donít knowÖ thereís no other cough quite

like it.

FARYON: Pertussis is a respiratory illness
caused by the bacterium bordetella pertussis.

At first, it can mimic a cold. But later produces
a violent and persistent cough, a cough that

leaves children gasping for air ñ creating
the distinct whooping sound. For adults, whooping

cough may only be a nuisance. In fact scientists
estimate more than 80 percent of adult cases

are never diagnosed because most people assume
they just have a bad cold. But to infants

whooping cough can be deadly, especially if
not diagnosed early.

DR. JAMES CHERRY: So with infection that you
eventually clear the bacteria and you get

better. But it's a prolonged, a good percentage
of cases will last one or two months.

DR. FRITS MOOI: After a pertussis infection
it has been shown to get super infections,

in fact that is one of the main complications,
pneumonia.

FARYON: Young babies arenít able to cough
up secretions that collect in their lungs,

leading to pneumonia and making it difficult
to breathe. Early antibiotic treatment is

most critical in this age group. Whooping
cough was nearly wiped out by the late 1970ís

because of mass immunization, but itís somehow
found its way back to California and other

highly vaccinated communities around the world.
Just why itís made such a vengeful comeback

has two of the worldís leading whooping cough
experts in disagreement.

Dr. James Cherry of UCLA:

CHERRY: The main reason is increased awareness.

FARYON: and Dr. Frits Mooi of the Netherlands
Centre for Infectious Diseases Control.

MOOI: We found really a new mutation in the
bug.

FARYON: Dr. Mooi and Dr. Cherry both began
their research into Whooping Cough about 30

years ago. Cherry in the U.S. and Mooi in
The Netherlands. The two scientists know each

other's work.

CHERRY: First of all, his molecular microbiological
is, he's right at the top of scholars. There's

no question about that. I think where some
of the things he's published is the clinical

data are not very good.

MOOI: I don't communicate too much with him
but what he wrote in the press is that I screw

up epidemiology. That doesn't help me too
much.

FARYON: To understand why these two experts
disagree, you need to know a little about

the history of the pertussis vaccine.

ANNOUNCER: Since most serious cases occur
before school age, immunization in school

may be too late.

FARYON: The bacteria that causes whooping
cough was first isolated in Belgium in 1906.

At the time, the illness was one of the leading
causes of infant death.

ANNOUNCER: In 1921, whooping cough killed
316 Michigan children. Last year, the number

of deaths was reduced to 63.

FARYON: The discovery lead to the first attempts
at a vaccine. But it wasnít until the late

1940ís scientists developed a vaccine effective
enough to prevent whooping cough.

ANNOUNCER: Unlike the disease however, a vaccine
does not endanger life.

FARYON: By 1946, mass immunization programs
began in the U.S. and the number of cases

dropped dramatically. Prior to the vaccine
the rate of disease was 157 cases per 100,000.

By the 1970ís, with large scale immunizations,
fewer than one in one hundred thousand people

got whooping cough. But the vaccine was not
without controversy. The early versions were

associated with side effects such as prolonged
crying spells and seizures in babies. By 1996,

the FDA approved a new whooping cough vaccine.
It was called an acellular version. That means

the vaccine uses only purified components
of the disease-causing organism. That vaccine

was considered to be safer and associated
with few mild side effects. Today, the U.S.

uses only the acellular pertussis vaccine.
But as the United States was changing vaccines

something else was happening ñ health officials
across the country were reporting increasing

numbers of positive whooping cough cases.
And in a government lab about 30 minutes outside

of Amsterdam, a group of scientists had discovered
something else ñ the bacterium that causes

whooping cough started to look a little different.

MOOI: This new mutation had the effect that
the bacteria started to produce more pertussis

toxin.

FARYON: Just whether that mutation is to blame,
at least in part, for the California epidemic

and outbreaks elsewhere in the world is at
the heart of the whooping cough debate. Dr.

Mooi believes this to be the case, but not
Dr. Cherry.

CHERRY: Even though these changes have occurred
there is no evidence that thatís lead to

increased vaccine failure.

FARYON: Here in San Diego County, more than
85 percent of children are immunized. In fact,

less than three percent of kids entering kindergarten
have not been immunized because of their familyís

personal beliefs. But despite the high immunization
rate, San Diego has the second largest number

of positive whooping cough cases in California.
Dr. Dean Sidelinger is San Diegoís deputy

public health officer.

DR. DEAN SIDELINGER: This is a disease that
if someone has it itís very easy to transfer

from one person to another. So if you or I
sitting here during this interview, one of

us had pertussis chances are we could transmit
that to the other person.

Sidelinger says in the past, the number of
whooping cough cases peaked in summer and

slowed by fall, but this year, that didnít
happen.

SIDELINGER: So as time goes on weíre seeing
more cases. We know that public awareness

plays into that as we talk about pertussis
more people are asking their doctors and doctors

are asking their patients weíre going to
see more, but that trend continued.

FARYON: By the end of November 2010, nearly
1000 infants, children and adults in San Diego

County tested positive for whooping cough.
More than half of them had been immunized.

Our investigation shows that trend continues
throughout California. KPBS and The Watchdog

Institute collected data from 9 California
counties that report some of the highest infection

rates. Our research shows that where immunization
history is known, between 44 and 83 percent

of people diagnosed with whooping cough were
vaccinated. We looked at California Department

of Public Health records too. In cases where
vaccination history was recorded, more than

80 percent of infected people had been immunized.

DR. MARK HORTON: From the epidemiology experts
and the experts in vaccine that this is absolutely

expected.

FARYON: Dr. Mark Horton is the director of
the California Department of Public Health.

HORTON: If you've got a percentage of the
population vaccinated and a percentage of

those vaccinated that are still susceptible
because the vaccine isn't perfectly effective

or effective in all individuals, when you
work out the arithmetic you'll see that even

with a very effective vaccine, and even if
you have the majority of the population vaccinated,

the pool of susceptibles will include a number
of individuals that have never been vaccinated

but will also include quite a few and in some
cases greater than 50 percent of the individuals

have been previously vaccinated.

FARYON: In other words, if you do the math,
you will always find a certain number of immunized

people getting sick if a vaccine is not 100
percent effective.

HORTON: So thatís no surprise to us nor is
it a reflection on the efficacy of the vaccine.

REPORTER KEVIN CROWE: Itís not a reflection
on the efficacy of the vaccine?

HORTON: Correct, correct.

FARYON: But 20 years ago, the reverse was
true. According to a report by the Centers

for Disease Control, more than half of the
children between 3 months and 4 years old

who got whooping cough nationwide between
1990 and 1996 were not immunized. The rate

of whooping cough has also been increasing
for the past 20 years. From less than one

in 100,000 to 18 per 100,000 here in California.
And in some California counties such as San

Luis Obispo, rates are nearly as high as before
vaccines were developed. Two days after our

interview with the Bryce family, Matthew got
a fever. He was hospitalized at Radyís Childrenís

Hospital in San Diego. Matthew was not immunized
against whooping cough. Heís too young. Babies

canít be immunized until theyíre two months
old.

But everyone else in the Bryce family was
vaccinated ñ even his parents got booster

shots. The practice of immunizing everyone
around a newborn baby is called cocooning.

CINDY BRYCE: When I called the doctor they
asked me who has it and I couldnít give them

an answer because I donít know where he got
it from because everyoneís been vaccinated.

FARYON: Myron and one of his sons were also
tested for whooping cough ñ both were negative.

M. BRYCE: The one thing I would want to know
is the vaccine working? Is it as effective

because before this I thought the vaccine
was working and I thought that if I did everything

that I was told to do that our sons would
be protected.

FARYON: Just how effective is the vaccine?
That all depends on who you talk to. Drug

information included with the two most commonly
used whooping cough vaccines in the US say

the vaccine is 85 percent effective.

MOOI: This new strain has completely invaded
the Netherlands and also other countries and

pushed out all the other strains. Itís quite
unique.

FARYON: Dr. Mooi believes thereís no way
to determine how effective the vaccines are

because they have not been tested against
the new strain of whooping cough.

MOOI: We call it the p3 strain.

FARYON: A strain he believes is more virulent
and can make people sicker. This strain emerged

while the new acellular vaccines were being
developed.

MOOI: I can tell you one of the reasons the
vaccine companies is not too happy with me

is because if what I say is true they selected
the wrong strains the in the 1980ís.

FARYON: Mooiís lab was studying the new strain
when The Netherlands experienced an unexpected

whooping cough epidemic in 1996.

MOOI: There were more strains in fact when
you compare the two there was a very direct

relationship between the emergence of these
strains, we call them p3 strains and the increase

in pertussis notifications.

CHERRY: Thereís absolutely no evidence that
either of the two vaccines that are most common

today used in the U.S. that there is increased
vaccine failure with either of those vaccines.

FARYON: So if you had to explain why weíre
seeing this epidemic the highest number of

cases in 60 years, what would you tell people?

CHERRY: The main reason is increased awareness.
People, particularly public health people

are much more aware and that trickles down.

FARYON: Cherry says the increase is also due
in part because of something called waning

immunity. Immunity to whooping cough does
not last a lifetime, whether you are vaccinated

or develop natural immunity from getting the
disease. Almost all experts agree waning immunity

is contributing to whooping cough outbreaks
worldwide. Where they disagree: when does

immunity fail? Dr. Mooi believes the new strain
of pertussis causes immunity to fail sooner

than in the past. And heís published his
findings in several peer reviewed journals

including the CDCís Infectious Diseases.

MOOI: When the immunity is sub-optimal what
will happen the bacteria will not be recognized

very well by the immune system because of
the mismatch and second of all even if immune

response is started in the body the toxin
will be able to delay it. You could say these

two changes work together by decreasing the
period of which the vaccine is protective

further.

FARYON: The Netherlands learned something
else after its 1996 epidemic. At the time,

it had very few samples of the bacteria that
was causing people to get sick. So Mooiís

lab began asking doctors and their labs to
send him positive pertussis swabs. His lab

now has 3,000 samples. California that has
collected just 29 samples from the more than

7,000 whooping cough cases in the state.
During the KPBS/Watchdog four month investigation,

we also learned data kept by the state and
the CDC was often lagging behind county data

and was inconsistent. While counties like
San Diego knew the immunization status of

the vast majority of people with whooping
cough, the stateís data listed the information

as unknown. Despite statewide protocols for
reporting pertussis, a KPBS/Watchdog survey

found some counties donít follow them or
are slow to report the information

HORTON: Thereís a perception that the more
numbers the better, but let me be very clear

we in no way need reports on every single
case of pertussis for us to make important

judgments and decisions about whatís happening.

FARYON: The CDC in Atlanta declined our requests
for an interview. In an email response they

said it is ìdifficult to disentangle all
the factorsî contributing to increases in

pertussis, but listed ìincreasing transmission,
better recognition, and increased laboratory

confirmation.î We also asked whether a new
more virulent strain could be contributing

to the outbreak. The CDCís response: ìAvailable
data do not suggest that ptxP3 is more virulent,

or that increasing reports are attributable
only to the emergence of ptxP3. We continue

to work on this and other potential explanations
for the increase in pertussis that has occurred

since the 1980s.î The CDC sent us this study
by their own investigators. The study looked

at children between 6 months and five years
old. It found pertussis vaccines to be more

than 90 percent effective. The study looked
at data between 1998 and 2001. It did not

collect pertussis strain information.

SINGING: Do you happen to know what a T-dap
is? It's a special vaccine but it's not just

for kids.

FARYON: Sanofi Pastuer, one of two companies
that make the vaccine widely used in the U.S.,

sponsored this singing competition earlier
this year.

SINGING: Persussis is the reason why you should
call your doctor today.

FARYON:

It was a public relations exercise to get
the word out about whooping cough and immunization.

But just where is the line between good PR
and trying to influence public health policy?

SINGING: Take a shot and give pertussis a
whooping.

FARYON: Especially when public health policy
can increase vaccine sales. Since 2007, the

California department of health has spent
more than $200 million on pertussis vaccines

for children on medical or who are under-insured.
And itís sure to rise. In September, the

California state legislature passed a law
requiring all students to receive another

does, a sixth dose of the pertussis vaccine
before entering middle school. It may be a

case of whatís good for business is also
good for public health. But how much influence

does industry have over public health policy?
Sanofi Pasteur also established and funds

The Global Pertussis Initiative. A group made
up of medical experts from around the world.

The GPI was established 10 years ago to study
why pertussis was making a comeback and find

ways to control the disease. More than half
its members are employees of the pharmaceutical

company or receive research money or consulting
fees. Public officials from across the country,

including California and the CDC, site the
Global Pertussis Initiative when making vaccine

policy. Dr. James Cherry is a member of the
initiative.

Heís also received speaking fees and research
funds from vaccine manufacturers. At the same

time, he sat on government committees to help
determine vaccine policy and efficacy.

FARYON: A cynic might say that if you have
a community of experts in pertussis as in

the Global Pertussis Initiative, who primarily
their work in terms of this endeavor is being

funded by the drug company that makes the
vaccine, there might be less incentive to

say make a new vaccine and more incentive
to say just use the old one more often. What

do you say to them?

CHERRY: I donít think thatís true. I think
that weíve been talking about new vaccines.

It think the difficulty with the new vaccine
lies in the expense that it would cost to

make a new vaccine and the difficulty in testing
it and FDA requirements for it and I think

if the climate was right for two of the major
manufacturers they would do it.

MOOI: And these are three different pertussis
strains.

FARYON: Dr. Mooi is a critic of the Pertussis
Initiative.

MOOI: My big disappointment is they have totally
and I think willfully ignored pathogen adaptation.

I think a few years ago we had the year that
Darwin died 100 year ago, it was not so long

ago, I think it's very strange that evolution
and pathogen adaptation is completely ignored

by such a group. I find that bad for science
and bad for public health.

FARYON: Sanofi Pastuer released this statement
to KPBS and the Watchdog Institute. It says

its grant to the GPI brings the world's authorities
on pertussis together and that benefits society

as a whole. The company also says ìat the
present time, there is no evidence to suggest

current pertussis vaccines lack effectiveness.î
Dr. Dean Sidelinger was one of the first health

officials to learn immunized people were getting
sick in his county. He said he was surprised,

but in the end, he says the current vaccine
is still the best thing heís got to protect

his community.

SIDELINGER: It does significantly decrease
the pertussis we see a significantly lower

number of pertussis cases now then we saw
before we started using the vaccine. So we

donít want people to feel complacent to say
I donít want that vaccine because Iíve seen

many of the cases that have been reported
were fully vaccinated.

FARYON: Sidelinger says there would be many
more cases if there was no vaccine at all.

Dr. Mooi agrees. He believes public health
officials should be encouraging cocooning,

immunizing all those around newborn babies.
But in the long run, he says we need better

vaccines. Baby Matthew spent four days in
the hospital and was eventually discharged.

Today, heís getting his two-month routine
check-up.

DOCTOR: I think it was just back luck heís
had two illnesses in a row and now the cold

he's building up his immunity.

FARYON: Despite a stuffy nose, Matthew is
doing well today.

DCOTOR: As you might know the vaccine is not
as effective as we want it to be. And that's

one reason why there've been a lot of cases.
But with Matthew in particular, his own immunity

has kicked in from having the illness, that
is, in effect a sort of a booster that will

protect him going forward. And how long that
immunity lasts is still a question.

MARLON: The one thing I would want to say
to parents is just watch your kids,
just be concerned. Because at first we thought

we were being over protective. But Iím glad
we were just a little bit over-concerned.

FARYON: Since KPBS and the Watchdog Institute
began its investigation, state health officials,

the CDC and scientists from UCLA, including
Dr. James Cherry, began a new study to determine

whether the new strain of pertussis is contributing
to the current whooping cough outbreak. For

more on this story, and to see more of the
data collected in our investigation, go to

kpbs.org/whoopingcough and watchdoginstitute.org.
For KPBS, the Watchdog Institute and Radio

Netherlands Worldwide, Iím Joanne Faryon.
Thanks for watching.