Article Available at: http://www.watchdoginstitute.org/2010/12/13/whooping-cough-epidemic-california/

Bordetella pertussis, the bacteria that cause whooping cough, are cultured in a petri dish in Dr. Jeff Miller's lab at the University of California Los Angeles.Mooi, the scientist who has been studying the bacterial mutations, said his research has been ignored by those who influence public policy on pertussis in the U.S. and beyond in part because they rely on vaccine makers to fund their meetings and research.

Matthew Jacob Bryce was born a healthy 8 pounds, 9 ounces on Oct 11, 2010, so when he showed signs of a cold at just two weeks, his parents knew something more might be wrong. They were not first-time parents.“He was just really stuffy. He was having difficulty breathing,” Marlon, Matthew’s father, recalled.The doctor suspected whooping cough, although everyone in the house had been vaccinated. For Marlon and Cindy Bryce, a young couple who had met in San Diego when both were in the Navy, it was a terrible prospect: whooping cough, known also as pertussis, can be fatal in babies.The doctor took a nasal swab, and started the infant on antibiotics.It took six days to get the lab results. Matthew, at 23 days old, had pertussis.California is experiencing its worst whooping cough outbreak in more than 60 years.

Thousands of people have gotten sick and 10 infants have died, including two in San Diego County.Health officials across the country are trumpeting pertussis vaccinations, but a four-month investigation by KPBS and the Watchdog Institute, a nonprofit investigative center based at San Diego State University, has found that many people who have come down with whooping cough have been immunized.Two of the world’s most respected experts on the disease disagree about why there are such high numbers of people are getting sick.

Dr. James Cherry, a prominent researcher at UCLA, says increased awareness of whooping cough has led to more reports of it. However, Dr. Fritz Mooi, a well-known Dutch scientist who has been studying mutations of the pertussis bacteria for 15 years, said a more virulent strain of bacteria is contributing to outbreaks.KPBS and the institute have been asking about the possibility of more virulent whooping cough strains for months, and the Centers for Disease Control and Prevention (CDC) recently announced studies of the disease, and the bacteria causing it, in California and Ohio. Two members of the California study group said it was prompted by the increasing death toll and KPBS-institute inquiries.Officials from the CDC, the California Department of Public Health and two pertussis experts from UCLA held a conference call Oct. 13 to discuss studying whether a more virulent strain was responsible for infant deaths and is contributing to the current epidemic. That same day, whooping cough claimed the life of its tenth newborn California.Dr. Jeff Miller, a scientist involved in the study at UCLA, said the possibility that the pertussis bacterium has mutated “is an important hypothesis to test.” He added, “I wish we would have started it in 2005.”Mooi, the scientist who has been studying the bacterial mutations, said his research has been ignored by those who influence public policy on pertussis in the U.S. and beyond in part because they rely on vaccine makers to fund their meetings and research.

There is little incentive for pharmaceutical companies to pursue a new vaccine because it would cost billions, he said. The circulation of a more virulent strain of pertussis could mean a new vaccine should be created.In examining the pertussis epidemic, KPBS and the Watchdog Institute collected federal, state and county statistics and consulted and interviewed experts from Los Angeles to the Netherlands.

Keys findings included:

• For pertussis cases in which vaccination histories are known, between 44 and 83 percent were of people who had been immunized, according to data from nine California counties with high infection rates. In San Diego County, more than two thirds of the people in this group were up to date on their immunizations.
• Health officials in Ohio and Texas, two states experiencing whooping cough outbreaks, report that of all cases, 75 and 67.5 percent respectively, reported having received a pertussis vaccination.
• Today, the rate of disease in some California counties is as high as 139 per 100,000, rivaling rates before vaccines were developed.
• Public officials around the world rely heavily on two groups of pertussis experts when setting vaccine policy relating to the disease. Both groups, and many of their members, receive money from the two leading manufacturers of pertussis vaccine.

Pertussis is a highly contagious respiratory illness that may mimic a cold for the first 10 days. It then can produce a violent and persistent cough with a unique “whooping” sound.For adults, pertussis may only be a nuisance, like a bad cold. But to infants it can be deadly because they can’t cough up what collects in their lungs and infections can spread.Vaccinations nearly wiped out whooping cough more than 30 years ago. But it has made a vengeful comeback in California and other highly vaccinated communities around the U.S.While public health officials and scientists agree that vaccines are still the best available tool against pertussis, they argue over how effective they are with time and in the face of a possible increase in virulence.

Dr. Mark Horton, director of the California Department of Public Health, said health officials expect to see a certain percentage of people who have been vaccinated contracting whooping cough. He says no vaccine is 100 percent effective, and those who are immunized and getting sick are likely those for whom the vaccine did not work or whose immunity has waned.“That’s no surprise to us,” he said, “nor is it a reflection on the efficacy of the vaccine.”Mooi, who heads the Pertussis Surveillance Project at the National Institute of Health in the Netherlands, said an epidemic in 1996 in his country gave the need for research more urgency.“And we found really a kind of new mutation in that bug,” Mooi said. In tests, Mooi’s lab found the mutated strain produced more toxins, which could make people sicker. 

At the Bryces’ home in Chula Vista, Marlon, who is 31 and a contract specialist at the Naval Medical Center, and Cindy, 27, puzzle over how Matthew could have contracted pertussis. He hadn’t been out of the house much, they said.Their other boys Jordan, 4, and Joshua, 3, were up to date on their vaccinations. Marlon had gotten his a month before Matthew was born; Cindy was immunized before leaving the hospital after giving birth.Marlon clearly remembers Cindy’s call when she learned Matthew had whooping cough. “She was crying… The moment that I heard it, I immediately started thinking the worst. You’ve heard the news about the babies that have passed away… Why is this happening?”Marlon is soft-spoken and thoughtful. “The one thing I would want to know is, is the vaccine working? Is it as effective? … I thought that if I did everything I was told to do that our sons would be protected.”

The bacterium that causes whooping cough was first identified in 1906, when the illness was a common cause of death in infants and young children.The discovery lead to the first attempts at a vaccine, but it wasn’t until the late 1940’s, when the rate of disease was around 157cases per 100,000, that scientists developed a vaccine effective enough to prevent pertussis. By 1970’s, the pertussis infection rate had dropped to less than one per 100,000.But the vaccine, made of whole bacterial cells killed in labs, had side effects, such as prolonged crying spells in babies and seizures.By 1996, the FDA approved a new whooping cough vaccine – an acellular version, which uses only purified components of the disease-causing organism. It is considered safer than the whole cell vaccine and is the only one used in the U.S. today.Just as the vaccines were changing, health officials across the country were reporting increasing numbers of whooping cough cases.

According to a CDC report, most of the children four years old and younger who got whooping cough nationwide between 1990 and 1996 were not fully immunized.That trend appears to have reversed in California’s latest outbreak.KPBS and the Watchdog Institute requested information from 19 California counties most affected by pertussis. Nine counties supplied pertussis case information and vaccination history. In all but Stanislaus County, more than half the people sick with whooping cough had been immunized.As of the end of October, and in cases where immunization history was known, data showed: 83 percent of the people with whooping cough in Fresno had been vaccinated. In San Luis Obispo, 76 percent were up to date on their immunizations. In San Diego, 68 percent were up to date.Public health experts say the surge of the disease is cyclical, with increased diagnoses every two to five years.“And that tells us bordatella pertussis is circulating today exactly as it did in the prevaccine era,” Cherry said. “The main reason is increased awareness,” he explained. “People, particularly public health people, are much more aware, and that trickles down.”Cherry and Netherlands scientist Mooi agree that immunity provided by vaccines wanes over time. But, they disagree over how long immunity lasts, and whether a mutated strain of pertussis is exploiting waning immunity.Package inserts included with the two most common pertussis vaccines in the U.S. state they are 85 percent effective. Cherry, who was involved in the efficacy studies when the vaccines were licensed by the FDA, estimated the efficacy is between 70 and 80 percent. Mooi said there’s no way to know how effective the vaccines are because they haven’t been tested against the new strain.“The vaccines have less efficacy than many people believe,” Cherry said.Mooi said there’s no way to know how effective the vaccines are because they haven’t been tested against the new strain.Public health agencies recommend five vaccine doses by age 6, and that adults get a booster every 10 years.

The California state legislature passed a law in September requiring all children entering middle school to receive a pertussis booster.Cherry advocates booster shots. Mooi isn’t so sure adult boosters are cost effective. But both agree that the current vaccine offers the best protection against the disease, especially for families with an infant in the house.In long run, Mooi says there should be better vaccines.Money should be spent studying today’s strains and making a vaccine that would work against them, Mooi said. “After all, every year we have a new flu vaccine, so, I think we should have something like that for bacterial vaccines, too,” he said.Cherry believes a new, better vaccine is a long way off.“I think the likelihood of the logistics of getting a new vaccine right now in this country is almost impossible, because of the FDA rules and requirements,” he said. “There’s a lot of things you could do (to improve current vaccines), but to get it approved would cost billions of dollars…” 

Cindy and Marlon Bryce were certainly aware of the deadly nature of whooping cough. Six weeks in October and November were harrowing for them. Today, their routine is more normal. Matthew has started day care.Stressful, frightening times teach powerful lessons.“The one thing I would want to say to parents is watch your kids, just be concerned,” Marlon said. “At first we thought we were being over protective. But I’m glad we were…“I would just hope that there is something we can do about this,” he continued. “If there’s something that we can do, If there’s something that the scientists who look at these things every day, if they think that there’s a better way to do this, if there’s a way that they can improve this vaccine, then please. I would support it.”

Freelance reporter Roxana Popescu, Watchdog Institute intern Sandy Coronilla and KPBS intern Jessica Plautz contributed to this report.KPBS is the Public Broadcasting affiliate in San Diego.



Bullit Marquez/Associated PressA mother in the Philippines used the warmth of her body to nurture her prematurely born daughter.

Sometimes, the best way to progress isn’t to advance — to step up with more money, more technology, more modernity. It’s to retreat.

Towards the end of the 1970s, the Mother and Child Institute in Bogota, Colombia, was in deep trouble. The institute was the city’s obstetrical reference hospital, where most of the city’s poor women went to give birth. Nurses and doctors were in short supply. In the newly created neonatal intensive care unit, there were so few incubators that premature babies had to share them — sometimes three to an incubator. The crowded conditions spread infections, which are particularly dangerous for preemies. The death rate was high.

Dr. Edgar Rey, the chief of the pediatrics department, could have attempted to do what many other hospital officials would have done: wage a political fight for more money, more incubators and more staff.

He would likely have lost. What was happening at the Mother and Child Institute was not unusual. Conditions were much better, in fact, than at most public hospitals in the third world. Hospitals that mainly serve the poor have very little political clout, which means that conditions in their wards sometimes seem to have been staged by Hieronymous Bosch. They have too much disease, too few nurses and sometimes no doctors at all. They can be so crowded that patients sleep on the floor and so broke that people must bring their own surgical gloves and thread. I recently visited a hospital in Ethiopia that didn’t even have water — the nurses washed their hands after they got home at night.

Rey thought about the basics. What is the purpose of an incubator? It is to keep a baby warm, oxygenated and nourished — to simulate as closely as possible the conditions of the womb. There is another mechanism for accomplishing these goals, Rey reasoned, the same one that cared for the baby during its months of gestation. Rey also felt, something that probably all mothers feel intuitively: that one reason babies in incubators did so poorly was that they were separated from their mothers. Was there a way to avoid the incubator by employing the baby’s mother instead?

What he came up with is an idea now known as kangaroo care. Aspects of kangaroo care are now in use even in wealthy countries — most hospitals in the United States, for example, have adopted some kangaroo care practices. But its real impact has been felt in poor countries, where it has saved countless preemies’ lives and helped others to survive with fewer problems.

Agence France-Presse A mother and child in Colombia, where the “kangaroo care” method was first used in the late 1970s.

In Rey’s system, a mother of a preemie puts the baby on her exposed chest, dressed only in a diaper and sometimes a cap, in an upright or semi-upright position. The baby is strapped in by a scarf or other cloth sling supporting its bottom, and all but its head is covered by mom’s shirt. The mother keeps the baby like that, skin-to-skin, as much as possible, even sleeping in a reclining chair. Fathers and other relatives or friends can wear the baby as well to give the mother a break. Even very premature infants can go home with their families (with regular follow-up visits) once they are stable and their mothers are given training.

The babies stay warm, their own temperature regulated by the sympathetic biological responses that occur when mother and infant are in close physical contact. The mother’s breasts, in fact, heat up or cool down depending on what the baby needs. The upright position helps prevent reflux and apnea. Feeling the mother’s breathing and heartbeat helps the babies to stabilize their own heart and respiratory rates. They sleep more. They can breastfeed at will, and the constant contact encourages the mother to produce more milk. Babies breastfeed earlier and gain more weight.

The physical closeness encourages emotional closeness, which leads to lower rates of abandonment of premature infants. This was a serious problem among the patients of Rey’s hospital; without being able to hold and bond with their babies, some mothers had little attachment to counter their feelings of being overwhelmed with the burdens of having a preemie. But kangaroo care also had enormous benefits for parents. Every parent, I think, can understand the importance of holding a baby instead of gazing at him in an incubator. With kangaroo care, parents and baby go through less stress. Nurses who practice kangaroo care also report that mothers also feel more confident and effective because they are the heroes in their babies’ care, instead of passive bystanders watching a mysterious process from a distance.

The hospitals were the third beneficiaries. Kangaroo care freed up incubators. Getting preemies home as soon as they were stable also lessened overcrowding and allowed nurses and doctors to concentrate on the patients who needed them most.

Kangaroo care has been widely studied. A trial in a Bogota hospital of 746 low birth weight babies randomly assigned to either kangaroo or conventional incubator care found that the kangaroo babies had shorter hospital stays, better growth of head circumference and fewer severe infections. They had slightly better rates of survival, but the difference was not statistically significant. Other studies have found fewer differences between kangaroo and conventional methods. A conservative summary of the evidence to date is that kangaroo care is at least as good as conventional treatment — and perhaps better.

In much of the world, however, whether a mother’s chest is better or worse than an incubator is not the point. Hospitals have no incubators, or have only a few. And millions of mothers never see a hospital — they give birth at home. In very poor countries, where pregnant women are unlikely to get the food and care they need, low birth weight babies are very common — nearly one in five babies in Malawi, for example, is too small. Nearly a million low birth weight babies die each year in poor countries. But thanks to kangaroo care, many of them can be saved. The Manama Mission Hospital in southwest Zimbabwe, for example, had available only antibiotics and piped oxygen in its neonatal unit. Survival rates for babies born under 1500 grams (3.3 lbs.) improved from 10 percent to 50 percent when kangaroo care was started in the 1980s. In 2003, the World Health Organization put kangaroo care on its list of endorsed practices.

Dr. Rey took a challenge that most people would assume requires more money, personnel and technology and solved it in a way that requires less of all three. I am not a romantic who wants to abandon modern medical care in favor of traditional solutions. People with AIDS in South Africa need antiretroviral therapy, not traditional healers’ home brews. If you are bitten by a cobra in India, you should not go to the temple. You should go to the hospital for antivenin. Modern medical care is essential and technology very often saves lives.

Kangaroo care, however, is modern medical care, by which I mean that its effectiveness is proven in randomized controlled trials — the strongest kind of evidence. And because it is powered by the human body alone, it is theoretically available to hundreds of millions of mothers who would otherwise have no hope of saving their babies.

But theoretical availability is only helpful for theoretical babies. Another of kangaroo care’s important innovations is that its inventors realized that ideas don’t travel by themselves. They established a way to get the practice from Bogota into hospitals and clinics all over the world — something that takes a lot more creativity and work than it sounds. On Saturday I’ll respond to comments and talk about how kangaroo care has been able to reach the places that need it most.



Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and now a contributing writer for the paper’s Sunday magazine. Her new book, “Join the Club: How Peer Pressure Can Transform the World,” is forthcoming from W.W. Norton.

This month’s issue of Obstetrics and Gynecology contains a compelling commentary by Dr. David Grimes, entitled Electronic Fetal Monitoring as a Public Health Screening Program: The Arithmetic of Failure.  Dr. Grimes states,

“Electronic fetal monitoring has failed as a public health screening program. Nevertheless, most of the four million low-risk women giving birth in the United States each year continue to undergo this screening. The failure of this program should have been anticipated and thus avoided had the accepted principles of screening been considered before its introduction.” 

He goes on to describe how electronic fetal monitoring (EFM) has both a poor positive predictive value (PPV) and poor validity.  PPV is the likelihood that an individual is affected with a condition when a screening test says s/he is.  Validity refers to the likelihood that a diagnosis, such as fetal intolerance of labor, actually results in a baby who suffered intolerance of labor.  Dr. Grimes sums it up very concisely:  “Stated alternatively, almost every positive test result is wrong.”

Ironically, while Dr. Grimes and Obstetrics and Gynecology are lamenting about the failures of electronic fetal monitoring, a hospital in my state is preparing to up the ante by increasing their fetal heart rate surveillance–only this time, they will be adding remote monitoring, computerized interpretation of fetal heart rate patterns, and a ” big brother” overseer to step in when concerning heart rates are identified.  The remote monitor will allow physicians to view the fetal heart rate tracing from anywhere, on a variety of electronic devices without actually having to be at the patient’s bedside.  The computer will “interpret” the pattern and recommend a course of management. (Here I envision the monitor struggling to pick up a fetal heart rate after the baby has been born but the monitor belts have not been removed from the mother’s abdomen.  A tinny, robotic voice in the background intoning, “Fetal heart rate is zero.  Proceed to c-section immediately.  Rapid response team has been activated.”)

Finally, “big brother” is a clinical nurse specialist or experienced labor nurse who will observe monitor strips and electronic charting from a remote location, possibly managing several hospitals at one time.  S/he will intervene by notifying the labor and delivery charge nurse if s/he determines that appropriate, standard management is not being followed in a timely fashion.  What will this mean in practice?  The woman who pushes for two hours and has not yet had her baby is taken for a c-section, despite her provider’s protests that she is making progress and can deliver vaginally.  The patient who reaches 41 weeks but does not want to be induced will be coerced into an induction because it is the “standard of care”, regardless of her personal circumstances and wishes.  The midwife who heretofore has been able to encourage her patients to walk during labor, and choose the position they want to use for delivery, will be compelled to keep her patient in bed on continual monitoring.  Come on, now, you didn’t think they would spend millions for this service and then actually allow patients not to utilize it?

As expensive as it would be to provide a trained labor nurse for each labor patient, a nurse who stayed in the room attending to her patient for the duration of labor, it would be much less expensive than this new equipment will be.  The increased cost for the computers, monitors, remote overseers, and maintenance will far outweigh the cost of a one-to-one labor nurse for each patient.  How about doulas, provided by the hospital, one for each patient?  Proven to dramatically reduce the incidence of c-section, this is a service rarely, if ever, provided by a hospital.

One physician in my state voiced his protests over the brave new world of computerized interpretation of fetal heart tones (FHTs):

“Last time I checked, the cesarean rate was at about 1:3 women admitted to L&D.  With such a remote “overseer” in place, able to second-guess the front-line care providers, the opportunity for defensive medicine and “physician intolerance for labor” will predictably lead to even higher cesarean rates…with, as all studies have shown, no neonatal benefit and very real maternal morbidity, both short and long-term.  . .Then there are the medical-legal concerns… and again, incentive for “defensive” medicine and earlier decisions for cesarean section delivery.  We all can think of many FHT’s that have been transiently labeled “pathologic” or “problematic” only to yield a healthy newborn with no long-term sequelae, many of which can be delivered vaginally with patience and appropriate timely responses, by understanding the larger picture of clinical risk and relevant physiology.[Computerized EFM interpretation] would tend to make the FHT way too central in the clinical calculus of intrapartum management and has to potential for contributing to adverse maternal, if not fetal, outcomes.”

Change is coming.  If consumers of OB care do not speak out against the trend that modern obstetrics is taking, it may soon be too late.  The wholehearted adoption of EFM in the 70’s, despite no evidence that it produced better outcomes, is a clear warning of how hard it is to go back once technological advances have become standard of care.