If we can’t stop measles, how will we stop a pandemic?

By Laura H. Kahn, April 15, 2015

In 2000 the United States declared measles eliminated. In 2004, though, the country saw 37 cases, and by 2014, the annual figure was more than at any time since the potentially deadly disease was banished. The availability of the highly effective MMR (measles, mumps, rubella) vaccine didn’t change over those 14 years. Rather, a growing number of parents started refusing to vaccinate their kids.

There are now calls to sue parents, or criminally charge them, for not vaccinating. But this punitive approach doesn’t get at the root of the problem: lack of political will and public mistrust. Only addressing these two issues will reverse the rise in cases of measles. The non-vaccinating parents may be wrong—but their refusal is a sign of much bigger problems.

The fact that governments and health officials have failed to convincingly communicate about the subject of vaccines is cause for serious alarm about the future of disease prevention and control. If the United States can’t stop the spread of an easily-preventable disease that was eradicated a decade and a half ago, how will it fare when it comes to a more existential threat—such as a disease like Ebola, SARS, or MERS—that turns into a global pandemic? Or a bio-attack that spreads deadly bacteria or viruses?

Victims of misinformation. The non-vaccinating parents’ concern primarily stems from a 1998 article published by Andrew Wakefield in The Lancet linking the MMR vaccine to developmental disorders in children. The study was subsequently found to be fraudulent, and many scientists and health officials have since worked to publicize accurate information, noting that the vaccine doesn’t cause autism, and that failing to vaccinate against communicable diseases causes them to spread. Unfortunately, though, the damage had already been done: Measles, and other vaccine-preventable diseases such as whooping cough, have returned with a vengeance.

Measles is one of the most communicable viruses known to medicine. If one infected person walks into a room, 90 percent of people present who are not immune will become infected too. And people who are infected but not yet showing signs of the disease can spread it to others. This makes contact tracing very difficult. 

The symptoms of measles include a cough, red eyes, a runny nose, and a high fever. But measles is most noted for the rash that appears three to five days before other symptoms hit. While many people consider measles to be a “benign” childhood illness, in the decade before the vaccine became available in 1963, an estimated three to four million people were infected annually in the United States—of whom 48,000 required hospitalization, 4,000 developed encephalitis (brain swelling), and 400 to 500 died. Today, even with a cheap and effective vaccine available, approximately 400 people around the world die from the disease every day. In 2013, the total number was more than 145,000.

In the United States, all states require that children be vaccinated before attending school—but all states also allow medical exemptions. Some children, such as those battling leukemia, should not get the MMR vaccine. Almost all states (except Mississippi and West Virginia) allow religious exemptions, and 18 states allow personal belief exemptions, which can include any philosophical objection.

The minimum vaccination level for “herd” immunity against measles is approximately 93 percent. “Herd immunity” refers to the proportion of immune individuals in a population. Of the 50 states, only 16 (plus two counties in Texas) have rates over 93 percent. Colorado, Ohio, and West Virginia have a three-way tie at the bottom with only 86 percent vaccination rates. Guam and the US Virgin Islands have appalling rates of 84.9 and 59 percent, respectively.

In 2013, California’s vaccination rate was 90.7 percent, too low to stop transmission. So it should have come as no surprise that when a measles case showed up at Disneyland in January 2015, the disease quickly spread; there have been 159 reported US measles cases this year, mostly in California. In response to public outrage, the California legislature is moving a bill forward that would ban personal belief exemptions.  

A need for leadership. Relatively high measles rates serve as good indicators of states (or countries) with weak political will and minimal public trust. The World Health Organization publishes international figures: While the United States doesn’t approach countries with sky-high measles rates of more than 30 cases per 100,000 people—like Namibia, Bosnia and Herzegovina, and the Philippines—in 2013, the United States had a higher measles rate than Chile, Costa Rica, and the Dominican Republic.

Political leaders should be held accountable. Rather than attack individual parents, which isn’t effective in changing minds, citizens should challenge leaders of US states that allow vaccine exemptions for religion or personal belief. State and local governments have the legal mandate to require vaccinations, stemming from the Massachusetts smallpox vaccination law of 1809. That law came about as part of the state’s effort to halt the spread of a disease that killed approximately 30 percent of those infected. It could be argued that leaders then were more capable of stopping disease than their counterparts today.

Gaining public trust will be even more difficult than challenging leaders, but is also essential. Simply giving people medical information will not suffice. For better or worse, the current generation of parents has minimal collective memory of the horrors of the diseases that vaccines have prevented. The American Academy of Arts and Sciences published a 2014 report recommending that more research be done to overcome the damage caused by a fraudulent scientific study, misinformed citizen activists, and irresponsible reporting. Following its advice may be a good start. Certainly trust requires transparency and honesty. But unfortunately, few studies exist that demonstrate effective strategies to overcome parental opposition to vaccinations. Figuring out how to do so should be a priority.

Vaccines are one of the greatest successes of medicine and public health, and yet people are refusing them. The measles vaccine is cheap, safe, and effective. Political leaders who cannot, or will not, control a disease as easily preventable as measles have much to answer for to the citizens of their countries and to the world. Their reluctance to make vaccinations mandatory will pose grave dangers the next time a potential pandemic begins to spread.


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