Ongoing Chickenpox Epidemic in a North Carolina School – November 2018

A school in North Carolina is currently experiencing a months-long epidemic of cases of chickenpox.  Part of the Waldorf Schools chain, the school (the Asheville Waldorf School, in Asheville, NC) apparently was long known for having a large proportion of its students unvaccinated.  The school’s proportion of unvaccinated students was among the highest in North Carolina, according to reports.  

North Carolina law requires that school students be vaccinated, BUT allows medical exemptions (such as in the case of an allergy to a vaccine component) as well as “religious” exemptions, although there are no major religions in the U.S. that object to vaccination.  In fact, most have voiced strong support for vaccination, which is widely accepted as keeping children healthy.  As you can see below, the “religious exemption” apparently has nothing to do with religion per se, but only requires parents to write a note that states their religious beliefs and their objection to vaccinations.  

This is taken verbatim from the Asheville Waldorf School’s website in the section on immunization:

Immunization Records: Each child must have a completed health and immunization form on file before being admitted.  This is a requirement of the county health department and state law.   NC law provides for the following two exemptions:  1. Medical exemption in which a licensed physician certifies in writing that an immunization may be detrimental to a person’s health. A form for this is available.  2. Religious exemption in which the parents submit a written statement of their bona fide religious beliefs, and opposition to the immunization requirements, after which the child may attend the School without presenting a certificate of immunizations.

The school has apparently been experiencing an ongoing chickenpox outbreak since September; however as of last week (2 months later) they had still failed to control it.  

This is from the school’s newsletter to all parents dated 9/26/2018: 

Dear Parents and Guardians,

We are writing to inform you that there have been a few more children that have possibly contracted Chicken Pox at AWS. It is likely there may be more cases that will pop up in the next week or so as we near the end of the initial incubation period from the first child that was diagnosed earlier in the month, so please be on the look out for symptoms in your children.

Chickenpox is a mild and common childhood illness caused by a virus called varicella zoster. It is most common in children under the age of 10 and is contagious. The incubation period is approximately 21 days and the person is contagious from 1 to 2 days before the spots appear until the spots have crusted over (usually 5-6 days after the spots appear).

Groups of people that are most at risk of serious problems if they catch chickenpox are newborn babies, pregnant women and those with a weakened immune system; therefore it is important, if your child has chicken pox, to keep them at home while they are contagious.

Our school policy states that if a child is suspected of having chickenpox, parents will be contacted immediately and asked to collect their child from school. All children should remain at home until all chickenpox spots have crusted over to avoid further spread of the illness. Should any child return to school before this time, parents will be contacted and asked to collect them and take them back home.

We appreciate your understanding on this and if you have any questions, please do not hesitate to get in contact with us.

Kind Regards,
The Faculty and staff of AWS

Read a story about the school’s outbreak from CNN here:

It is not known if the Asheville Waldorf School made it clear to parents of current or incoming students that their school had a large number of children who were unvaccinated.  If they did not, and a child with a true medical exemption (say, a child with leukemia still getting chemotherapy) was infected by a healthy student whose parents claimed a so-called “religious exemption,” would the former child’s parents blame the school (and the other student) for hospital costs and medical complications?  Or, in this litigious world, what about a child who was infected by a classmate and whose mother simply missed a week of work from her very well-paying job in the busiest season of the year?

When a school (or preschool, or daycare center) has a stated policy that requires vaccination yet allows “exemptions” on the basis of nothing but a note from a parent, that institution is asking for epidemics like this to occur.  Since universal vaccination is known to be safe and to keep students healthy, how does a school justify not enforcing state policy???  If there is a complication from such a preventable illness, the school might easily be considered at fault by failing to adhere to infection control guidelines.  For a parent to claim “religious freedom” when there is NO religion that prohibits vaccination is deceptive.  For a school to accept such a flimsy excuse is neglecting its obligation to its own students. 

Although chickenpox is normally a mild disease (characterized by fever, lethargy, and blisters on the skin), it often lasts a week or longer, causing parents to miss work.  More importantly, chickenpox in very young infants can be much more serious, and potentially fatal to the very young and the very old.  About 1% of patients with chickenpox are hospitalized with a complication, and about 1% of those hospitalized (or 1 in 10,000 patients) die of the disease or its complications.  

So what is a state to do?

In California, a law was passed in 2015 that prohibited all personal and religious exemptions, while maintaining the exemption for true medical conditions.  The result was a sustained increase in vaccinated children throughout the state.  Why is every other state not following its lead????

What are your thoughts??  Please comment.

Vaccines recommended for travel – holiday edition

For those traveling out of the U.S. for the winter holidays, many children should be getting travel vaccinations.  Although most vaccinations recommended for travel for children are already given routinely, several are suggested to be given at an earlier age prior to upcoming international travel.  High on this list are those for Hepatitis A and measles.  Although vaccines both are normally given at age 1 year, both are currently recommended by the CDC for infants to be given earlier – between 6 and 11 months old – for ANY international travel (for measles) and to most of the world, with the exceptions of Canada, western Europe New Zealand, Australia and Japan (for Hepatitis A).  Luckily, these are vaccines that your pediatrician’s office already has in stock!  See for complete information.

Hepatitis A:

Until recently, Hepatitis A vaccine was already given starting at age 12 months to infants in the U.S.  If travel to a high-risk area was anticipated, the only option before 1 year of age was to give IgG, also called “gamma globulin.”  However, since this is a human blood product, this is not ideal at any age.  Now, Hep A vaccine can be given at the age of 6 months or older.  The CDC press release states “People 1 year of age and older who are traveling to or working in countries where they would have a high or intermediate risk of hepatitis A virus, should strongly consider the Hepatitis A vaccine.  These areas include all parts of the world except Canada, western Europe and Scandinavia, Japan, New Zealand, and Australia.”  The following quote is taken from the CDC website: 

“Infants aged 6–11 months. HepA vaccine should be administered to infants aged 6–11 months traveling outside the United States when protection against HAV is recommended.”


Similarly, measles vaccine is routinely given starting at 12 months in the U.S., but since measles is endemic (common and widespread) in many countries, for several years it has been recommended that infants from 6-11 months receive a measles vaccine (that is, MMR) prior to travel.  Again, the CDC’s language:

“People 6 months of age and older who will be traveling internationally should be protected against measles. Before any international travel—

Infants 6 through 11 months of age should receive one dose of MMR vaccine.

**It is important to add that these doses of MMR and Hep A vaccines do not “count” towards the 2 doses of each that they will still need to get later on according to the standard vaccination schedule.

There are also numerous other vaccines and medications recommended for international travel.  For example, for travel to many parts of the world, it is recommended to get typhoid and yellow fever vaccines.  Likewise, for many destinations it is highly recommended to use medication to prevent malaria, which can be done safely and effectively for infants as small as 11 lbs.  See for more information.

Influenza update: October edition

OK, everyone, it’s officially flu season – we are seeing influenza in emergency departments and hopefully all doctors are in full swing of giving flu vaccinations to any and all who want them.  My office in particular is giving both injectable (“killed”) flu vaccine and the nasal spray (“live”) flu vaccine.  Between the 12 of us docs there’s a pretty even split between what we all prefer, although patients/parents make the ultimate choice if either one is appropriate for the patient’s age and medical condition.  We continue to get the question “Well, I didn’t give [my child] the vaccine last year and he/she was fine – why should we give it this year?”  The simple answer is, whether or not one will get the flu in a particular season, and how severe a case one might get, is impossible to predict.  But pretty much all public health authorities agree that gambling on staying healthy without vaccination is a bad bet.  Last year we had one of the worst flu seasons on record, with around 80,000 deaths in the U.S., mostly among those who were not vaccinated.  The downside to getting a vaccine (the inconvenience of showing up and the pain IF you get the shot and not the nasal spray) pales in comparison to the downside of getting a bad case of the flu.  Period.

Also, see this NPR story on someone who gambled and lost:

Australia set to ‘eliminate’ cervical cancer by 2028

Australia has just announced that it is on track to banish cervical cancer (caused by human papilloma virus infection) in the next 10 years!  As you likely know, this is the virus that causes most cases of cervical cancer, genital warts, anal cancers and many head and neck cancers.  You may also know that although we have had the same vaccines and screening tests for a while, in the U.S. our vaccination rates are dismally low compared with some other countries.  Not only will Australia save many lives and prevent many surgeries with this milestone, it will also save tremendous amounts of money on having to care for these illnesses.  Here’s the link:



Vaccines for Pregnancy (not strictly a pediatric topic)

For pregnant women, there are a number of vaccines to be thinking about during the pregnancy which can help protect your baby.   Although this is always at your pregnancy provider’s discretion, the most common vaccines to be talking about  would be influenza (especially from September through May), Tdap and (maybe) MMR.

  • Influenza vaccination is considered very important to receive if you will be delivering between September and June.  Pregnant women who get influenza have higher rates of premature labor and of influenza complications.  Just as importantly, some antibodies (immune proteins) are passed through the placenta to the fetus, helping to protect your baby from influenza after birth while he or she is still too young to get a flu vaccine. Also recommended for partners and others who will be spending a lot of time around the baby, such as family members (this concept is known as “cocooning” or surrounding the baby within a web of protected people to decrease possible infection).  Normally given once annually, September through April or May.


  • Tdap (tetanus, diphtheria and pertussis) vaccine is given to help to protect you and your baby from pertussis.  In adults, pertussis can cause a high fever and prolonged cough; in newborns the respiratory infection can be fatal.  As above, also recommended for partners and others who will be spending a lot of time around the baby, such as family members.  Given to pregnant women during the third trimester of EACH pregnancy; for all other adults, given only once.


  • MMR (measles, mumps and rubella) vaccine is actually not given during pregnancy but sometimes is given after delivery.  During pregnancy women are tested for immunity to rubella, since contracting rubella during pregnancy may lead to congenital rubella syndrome in infants, characterized by cataracts, heart disease, hearing problems, and developmental delays.  This is now rare in the U.S. due to universal vaccination of children at 1 and 4 years old.  However, if a woman is found to be “non-immune” to rubella during pregnancy, the standard is for her to receive MMR vaccine right after delivery to prevent possible infection during future pregnancies.  Given after delivery if not found to be immune during prenatal testing.

Has your child gotten a flu vaccine yet? Which one?

Let’s see which vaccine kids are getting and why.

Hi all – it’s September, which is the unofficial start of flu vaccine season!

Since this year we have flu vaccine choices again (shot or nasal spray), and different recommendations from different organizations (i.e. CDC and AAP), I wanted to survey people to see what their docs recommend and what their child(ren) receive.  With FluMist (nasal spray influenza vaccine) back on the scene but no data on its effectiveness until December 2018 at the earliest, this will be an interesting flu season.

Please use the comments box below to let us know.  I will tally results every week or so and post here, so check back for updates.

Remember, it is very important to have your child vaccinated, whichever method you choose.  Earlier is better, so just do it!

Also, if you are pregnant, please get a flu vaccine ASAP (although I’m sure your obstetrician or nurse midwife is already on top of this).  Also any partners or others who will be spending significant time with your baby (i.e. grandparents) should receive one as well.


Lead in Our Schools (ok, not a vaccine topic)

In the past few years there have been lots of reports of large cities finding lead in their drinking water.  Of course, Flint, MI comes to mind, and they are STILL working on that, but with the new school year come more reports about schools finding high levels of lead in their water fountains.  This necessitates turning off the water fountains and bringing in bottled water for students and faculty to drink (which, aside from being very expensive, is a landfill nightmare if they are using disposable plastic water bottles).

Here’s a story from this week’s Wall Street Journal and here’s another from last week.

Older pipes are much more likely to be lined with lead, and lead was also used to solder pipes together in the past.  This is why older cities with older building and older water supplies bear much of the lead burden (it is similar in homes with lead paint: old house=lead hazard).  Lead is a heavy, durable metal, which was used in the past in plumbing, paint, even fishing (in fact, lead “sinkers” are still made and sold).  When the problem in Flint emerged, it was discovered that officials making critically important decisions about water sourcing were well-informed about budgets, but not about the science of preventing lead leaching out of older pipes.  Since city water mains are very large and very buried, they are tremendously difficult and expensive to replace.  Luckily, most districts probably have water that is safe, and also luckily, most problems with lead in older city buildings come from water in the pipes within the buildings, not in the water mains under streets and highways, so the fixes are a little easier.  But you don’t know about any building unless you take the time and trouble to find out.

Part of the problem is that there is no federally mandated testing of schools, although some states require periodic testing.  Less than half of school districts in the U.S. reported testing their water for lead in the last 2 years.  The EPA (already a very leadership-challenged agency, as you may know) recommends testing and also recommends maximum safe cutoff levels of 20 parts per billion (or ppb), but there are no mandates and so school districts are left to create policies on their own.  Unfortunately, this is not what school officials are expert in, so everyone does things differently, and many, many districts are not even testing.  In fact, the recommended maximum lead level of 20 ppb was set over 20 years ago – and since then the recommended “action level” for lead in blood tests done on very young children has been lowered twice, without any changes to the recommended maximum levels found in school drinking water.  Lead is known to be toxic to humans at any level, and can affect most organs and body systems.  Some of its most dangerous effects are on the developing brain, especially in infants and young children.

I think this should be seen as a public health emergency – the fact that we are not seeing higher lead levels in many older children due to aging pipes in schools and home is because many children are not tested for lead after they become toddlers or preschoolers.  We would not accept this level of municipal neglect in our home drinking water (again, see Flint), so why is it ok in our schools?  As parents of children in school, we should be thrilled when our children make a choice to drink water from a water fountain, which is cheap, healthy, and environmentally thoughtful.  Parents should demand that their school districts both test the water in each school and make the results known to parents.  If levels are safe, great, but if not, we all need an action plan.