Held by his mother, this infant receives immunization in his left thigh muscle. Photo courtesy of the CDC.

This would be a great horror film, but instead is an amazing case study: What happens when people stop vaccinating against childhood diseases? The diseases come back, with a vengeance. Who would have expected that a trip to the Happiest Place on Earth over the Christmas Holidays could have led to a measles outbreak affecting at least 14 states and counting?

Between 2001 and 2010, the United States saw about 60 measles cases per year, according to Dr. Anne Schuchat, assistant surgeon general and director of the Center for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases. 

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In the first 28 days of 2015, 84 measles cases have been reported in 14 states. All ages are affected: from seven-month-old infants to 70 years old, with the median age being people in their 20s. In 2000, health officials had declared measles was eliminated from the U.S. 

In 2014, there were 644 confirmed measles cases in the U.S. 

Why is it that a disease that is so preventable has struck back with a vengeance?

Lack of Community Immunity

Once infected, a person can spread the virus four days before they show symptoms. You can be walking around Disneyland, spreading the disease to every non-immune person with whom you come into contact and 90% of them will become sick.  The only reason the current numbers don’t reach the rates of the 1950s is because most people are vaccinated. We rely on the immunity of the community to prevent the virus from spreading.

But what of those who are not?  People who chose not to vaccinate accounted for 79% of the cases in 2014. In the current outbreak, most of those who became ill were unvaccinated or did not know if they had been vaccinated.  Some of those were infants less than 12 months old, too young to be vaccinated. And therein lies the problem: Choosing not to vaccinate not only puts your own child at risk, it puts at risk all those who can not be vaccinated for medical reasons.

This late 1960s photograph shows a Nigerian mother and her child who was recovering from measles; note that the skin is sloughing on the child as he heals from his measles infection. Photo courtesy of the CDC.
This late 1960s photograph shows a Nigerian mother and her child who was recovering from measles; note that the skin is sloughing on the child as he heals from his measles infection. Photo courtesy of the CDC.

The anti-vaccinator usually says, “Why are you worried if you’re vaccinated?” Because no vaccine is perfect. Vaccine efficacy for measles is close to 95%, depending upon when the doses are given.  

That means that 5% who are vaccinated will become ill, more if they only received one dose. And then there are the immunocompromised: Brandi Schemerhorn has two children with juvenile idiopathic arthritis.  The medications that they take are immunosuppressants, which means they cannot have live vaccines, which includes MMR.  They are entirely dependent upon the immunity of the community to keep their children safe.

Dr. Jack Wolfson, an Arizona cardiologist who practices holistic medicine, describes these diseases as a right of passage. But what about those who don’t pass through it, those that die or suffer debilitating consequences? In the U.S., one in every 1,000 cases will suffer encephalitis. One or two in every 1,000 will die. Since the vaccine was introduced in the 1960s, we have not seen that number of cases in the U.S. Will this be the year?

The potential link between autism and the MMR vaccine was studied extensively and debunked.  Now parents are worried about “putting toxins in our children’s bodies,” and have a distrust of the pharmaceutical establishment

Big Pharma” makes far more from your child being diagnosed with ADHD than it does off of two doses of MMR in a lifetime. 

One anti-vaccinator said she would not vaccinate because if her child gets a disease naturally, that’s just “one of those things,” but an adverse vaccine reaction is due to a parental choice. She said she couldn’t live with it if her choice to vaccinate led to severe illness or death.  When told her choice to not vaccinate is more likely to result in severe illness or death, she replied, “but that won’t be my fault because I’m not choosing for my kid to get the disease.”

If you’re playing the risk-benefit game, the risk of getting the disease, and suffering consequences from it, is much higher than the risk of adverse reactions. 

It’s tempting to write off non-vaccinators as ignorant, but many non-vaccinators are extremely smart, capable people (the person noted above has a PhD in a scientific field).  Knowledge in one area doesn’t make us an expert in all: I know a lot about infectious disease, but NASA isn’t going to ask me to develop a rocket.  Similarly, my rocket scientist husband will ask me to explain vaccines to him.  We are both “stupid smart people.” 

Personal Belief Exemptions, by state. Texas law has some of the most lax exemption requirements (Chapter §97.62).  A parent need only sign a statement and file it.
Personal Belief Exemptions, by state. Texas law has some of the most lax exemption requirements (Chapter §97.62). A parent need only sign a statement and file it.

Public health is partially to blame. For years we wrote off Andrew Wakefield and his ilk as quacks to whom no one would listen. Then the opposite happened, and the anti-vaccination movement gained steam. Not only has the theory been disproven, Wakefield’s paper was retracted by its publisher and Wakefield lost his license over falsification of data. Yet his credibility with uninformed continues.

Vaccination rates have climbed again in recent years but have yet to recover to pre-autism scare levels.
Vaccination rates have climbed again in recent years but have yet to recover to pre-autism scare levels.

See this New York Times story published today: A Discredited Vaccine Study’s Continuing Impact on Public Health.

Not all non-vaccinators made an active decision not to vaccinate. One parent describes a combination of factors: busy single mom, no health insurance, little time to wait in long lines in public clinics. Eventually the child received one dose of MMR, but was behind in other vaccines. Once she had insurance, most pediatricians refused to take her on as a patient because she was not up to date on vaccines. Finding one who would, insurance hassles again prevented it. This parent wants to vaccinate her child, but the system hasn’t made it easy.  The cost of childhood vaccines are covered by the Vaccines for Children program, but access to a provider can be problematic.

Here’s the good news: in Bexar County, 93% of children have been vaccinated for MMR

That sounds pretty good, except in some communities, the rates are much lower.

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Then there’s the bad news: vaccine rates for all required childhood vaccinations are only at 71%.

And more bad news: the rate of “Personal Belief Exemptions” in public schools in Texas has increased dramatically (see graph).

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One hope is that we’ll see the Disneyland Effect, that given the outbreak, anti-vaccinators will rush out to vaccinate.  Unfortunately, research suggests that even photos of dying kids is not enough to sway people.

So how do we get people to trust public health? We can’t simply blame anti-vaccinators – they’re parents worried for their kids.  We must continue to educate, to explain the science, to improve access to health care to make it easier to get vaccines, to continue to research vaccines, studying potential adverse reactions, and improving them. 

*Featured/top image: Held by his mother, this infant received an immunization in his left thigh muscle. Photo courtesy of the CDC.

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Cherise Rohr-Allegrini

Cherise Rohr-Allegrini

Cherise Rohr-Allegrini is an infectious disease epidemiologist and consultant. She is currently the San Antonio Program Director for The Immunization Partnership. Dr. Rohr-Allegrini was the Pandemic Flu...