Dropping the Ball at Day Care

For as long as humans have gathered in societies, perhaps even before we evolved into homo sapiens, we have engaged in the communal care of our children. Whether it is a collection of parents, sharing responsibility for the care and upbringing of the youth; a single parent caring for several neighborhood kids; or even modern professional facilities; to one degree or another, there has always been a need, on occasion, for a division of labor when it comes to taking care of infants, toddlers and older children.

Today, this most often takes the form of day care. The demands of working life lead us to put our trust in others to watch after our children while we go off to earn a living to provide for our families. The opportunity to stay at home, to spend time with our kids, is often a luxury that few can afford. This may be due to the necessity of simply earning enough money to pay for rent and other bills or the need to advance in our careers. Whatever the reason, there are many for whom day care is a necessity, and as such, we trust that those in charge will take appropriate measures and put in place certain rules to ensure the well-being of those under their care. We also trust that all parents who use those resources will abide by the rules.

When the system breaks down, the repercussions frequently ripple outward, affecting more than just one or two people who failed to uphold that trust.

Back in late November/early December 2011, one of the employees of a day care center noticed something wrong with one of the children. A two-year-old had begun developing pustules. The child was taken to a doctor, and samples were sent to a lab for confirmation of a diagnosis. Then another child developed similar symptoms. This was followed by the 6-month-old sibling of the first child, and then their older, pre-school-aged sibling. The day care had an outbreak of varicella, chicken pox (PDF), on its hands.

How could this have happened? All children attending the child care center, aged 1 year or older, were supposed to have been vaccinated against chicken pox (PDF example of typical requirements). Was this a failure of the vaccine? A faulty lot of vaccine? Did the facility knowingly allow the children in without their shots? Did the parents get a religious waiver for their children?

It appears that there have been no problems with any vaccines that children at the day care received. There were no waivers from the immunization requirements due to religious beliefs. And the day care apparently thought that all of the kids were properly vaccinated. So what went wrong?

The parents of the four children are allegedly pleased that their kids got wild type chicken pox, since it seems they harbor a distrust of vaccines and feel that infection is better than the vaccine. Based on reports, the parents faked the vaccination records of the three oldest children (the 6-month-old is too young for the varicella vaccine) so their kids could be admitted to the facility without actually receiving their shots. Compounding the issue is that it appears the day care center may not be exactly stringent in checking immunization records for validity.

Since only fatal cases of varicella are reportable (PDF example of typical requirements) to state health officials, investigators may never have heard about this little outbreak. The four infected apparently have had a normal course of illness without severe complications. Thus far, no other children at the center have been reported as being infected, though there is still a chance that they could get chicken pox, even if vaccinated, since efficacy against infection is about 80%-85% (though if infected, those who have been immunized will have their risk of moderate or severe disease reduced by 95%-100%).

However, more than just the children at the day care were at risk. Two of the center's staff were pregnant. One had been immunized, the other had not and did not recall whether or not she had chicken pox as a child. Because this second woman had unknown immune status, she was referred to an OB/GYN and given immune globulin to try to prevent any possible infection from taking hold, though this would likely only have protected the mother.

Varicella infection while pregnant can be quite dangerous for both the mother and the fetus. According to the CDC, about 10%-20% of infected mothers will develop varicella pneumonia, and of those approximately 40% may die. The infection can cause pre-term labor or even premature delivery (PDF). The mother may also suffer from respiratory distress severe enough to require intubation and ventilator support.

Image from CDC

The infection may also play havoc with the developing fetus. In about .5%-1.5% of cases, the fetus may develop what is known as congenital varicella syndrome. On the mild end of effects, the infant may be born with scarring or other skin abnormalities from the pox marks. More extreme, though by no means rare, effects, especially if the infection occurs during the first two trimesters, are low birth weight, uneven or incomplete physical development (e.g., a shortened leg or arm), mental impairments, nervous system disorders, impaired vision and so on. Infants thus affected can also look forward to bouts of shingles, which typically affects older adults, during childhood.

In light of these not insignificant risks to the pregnant day care staff, the magnitude of the situation should be clear. The combination of events (parents not immunizing their children and allegedly hiding the fact, the day care possibly failing to do due diligence in reviewing immunization records for their clients) highlights the community aspects of vaccination. Immunization is one of those things that is about more than just the one patient. As I have said before and will say again, any person's decision about whether or not to vaccinate themselves or their children has repercussions. It affects every single individual with whom the person comes in contact, even the unborn.

In the setting of the communal care of children, it is incumbent upon everyone involved to do what they can to protect everyone connected. Parents need to follow immunization requirements and providers need to ensure compliance. It takes a village, as the saying goes, to raise a child, and selfish or careless acts threaten not only the child, but the entire village.

Note: Names and locations have been omitted to protect the identities of the individuals involved in the outbreak.