When Immunity Fails: The Whooping Cough Epidemic

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

Hello, Saya Joanne Faryon.

Selamat datang di acara khusus malam ini. Ketika Kekebalan Tubuh Gagal: Epidemik Batuk Pertussis.

Kita akan mendalami batuk pertussis terparah yang merajalela di California

dalam 60 tahun ini.

Mengapakah penyakit yang hampir punah 30 tahun yang lalu ini,

kini kembali lagi, dan yang lebih parah

menyerang ke seluruh negara di dunia?

Apa yang kami temukan mungkin akan mengagetkan.

Pertanyaan serius tentang seberapa kuatkah vaksin

dapat mencegah penyebarluasan penyakit

pertanyaan-pertanyaan resmi ke departemen kesehatan

yang lamban direspon.

KBPS bergabung bersama Watchdog Institute,

sebuah pusat investigasi jurnalisme

di Universitas San Diego,

dan jaringan Radio Netherlands Worldwide untuk mengungkap kisah ini.

Kisah yang membawa kita melintasi California

hingga ke 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, 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: 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 wasn't any whooping

or they always say there is a whooping or a cough,

he didn't have a cough or anything it was just

that there was a cold.

FARYON: Matthew's 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 we'll 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?

We'll show you how some of the experts

who influence vaccine policy are financially tied

to vaccine companies.

And, we'll follow the Bryce family as they struggle

with their son's 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

don't know...

there's 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 -

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, most cases ...

a good percentage of cases in children

will last for one or two months.

DR. FRITS MOOI: After a pertussis infection

you often get super infections, actually that is one

of the main complications, pneumonia.

FARYON: Young babies aren't 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 1970's

because of mass immunization,

but it's somehow found its way back to California

and other highly vaccinated communities around the world.

Just why it's made such a vengeful comeback has two

of the world's 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 science 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 wasn't until the late 1940's 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 1970's, 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

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 -

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 that's 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 family's 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 Diego's deputy public

health officer.

DR. DEAN SIDELINGER: This is a disease

that if someone has it it's very easily transferred

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 didn't happen.

SIDELINGER: So as time goes on we're 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 we're 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 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 that's no surprise to us nor is it a reflection

on the efficacy of the vaccine.

REPORTER KEVIN CROWE: It's 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 Rady's Children's Hospital

in San Diego.

Matthew was not immunized against whooping cough.

He's too young.

Babies can't be immunized until they're two months old.

But everyone else in the Bryce family was vaccinated -

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 couldn't give them an answer because I don't know

where he got it from because everyone's been vaccinated.

FARYON: Myron and one of his sons were also tested

for whooping cough - 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.

It's quite unique.

FARYON: Dr. Mooi believes there's 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 are not too happy

with me is because if what I say is true they selected the wrong

strains in the 1980's.

FARYON: Mooi's lab was studying the new strain

when The Netherlands experienced an unexpected whooping cough

epidemic in 1996.

MOOI: There was a very direct relationship

between the emergence of these strains, we call them p3 strains

and the increase in pertussis notifications.

CHERRY: There's 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 we're 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 he's published his findings

in several peer reviewed journals including the CDC's

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 Mooi's lab began asking doctors and their labs

to send him positive Pertussis swabs.

His lab now has 3,000 samples.

California 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 state's data listed the information as unknown.

Despite statewide protocols for reporting pertussis,

a KPBS/Watchdog survey found some counties don't follow them

or are slow to report the information HORTON:

There's 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 what's happening.

FARYON: The CDC in Atlanta declined our requests

for an interview.

In an email response they said it is "difficult

to disentangle all the factors" contributing to increases

in pertussis, but listed "increasing transmission,

better recognition,

and increased laboratory confirmation."

We also asked whether a new more virulent strain could be

contributing to the outbreak.

The CDC's response: "Available 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."

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: Pertussis 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 it's sure to rise.

In September, the California state legislature passed a law

requiring all students to receive another dose,

a sixth dose of the pertussis vaccine before entering

middle school.

It may be a case of what's 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.

He's 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 don't think that's true.

I think that we've 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 because of FDA requirements for it and I think

if the climate was right for either of 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 Pasteur 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 "at the present time,

there is no evidence to suggest current pertussis vaccines

lack effectiveness."

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 he's 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 don't want people to feel complacent or to say I don't want

that vaccine because I've 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, he's getting his two-month routine check-up.

DOCTOR: I think it was just bad luck he's 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 going around.

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 ...

is just watch your kids ...

just be ...

just be concerned.

Because at first we thought we were being over protective.

But I'm 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, I'm Joanne Faryon.

Thanks for watching.