The measles outbreaks in the USA this year – the 387 reported cases in 15 states is the second-largest figure in two decades – highlight the importance of fighting off the disease through immunization.
The urgency to address the issue has been far from uniform, however. Affected states are more likely to take legislative steps once they’ve encountered a crisis. That has left others in a reactive position as a disease once considered eradicated vies for a comeback.
“I think most of the momentum, unfortunately, is just in the states that have had problems,’’ said Health Commissioner Mark Levine of Vermont, which has pending legislation that would disallow the religious exemption to vaccines after doing away with the philosophical dispensation in 2016. “There’s no problem framing the problem. But not everyone buys into that until they have the problem themselves.’’
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Take the case of Washington, one of 17 states that allows personal-belief or philosophical exemptions from vaccinations, in addition to the medical one permitted by all states and the religious dispensation that’s in effect in all but California, Mississippi and West Virginia.
A severe measles outbreak linked to a traveler from Eastern Europe erupted in Clark County, on the southern edge of the state, north of Portland, Oregon, in early January, prompting Democratic Gov. Jay Inslee to declare a state of emergency.
Of the 74 cases reported in Washington, 73 have been identified as stemming from Clark County, where the vaccination rate for kindergartners dwindled from 91.4% in 2005 to 76.5% – far below what’s required for herd immunity – last year. Sixty of those who contracted the illness were unvaccinated; the immunization status of most of the rest could not be verified.
Vaccinations in the county nearly quintupled for minors and multiplied exponentially for adults in the weeks after the outbreak, but by then, the highly contagious and potentially fatal disease had taken a devastating health toll.
The outbreak has cost state and local health departments more than $1.6 million, which could have paid for immunizing 40,000 people with a vaccine that costs $20 a shot and requires two doses for 97% effectiveness.
“Prevention works, and it saves community resources,’’ said Michele Roberts, director of Washington’s Office of Immunization and Child Profile.
Two legislators from Clark County introduced bills that would have eliminated personal-belief exemptions for school-age children, one applying to all vaccines and the other one only to the measles-mumps-rubella (MMR) immunization.
The first one was defeated, but the latter one, House Bill 1638, made it out of that chamber and is in the state Senate.
In an address March 5 to a congressional committee, Washington Secretary of Health John Weisman said, “Public health systems at every level are struggling due to chronic underfunding, increasing population size and the emergence of new threats. We find ourselves constantly reacting to crises, rather than working to prevent them.’’
'A moral law'
That was the case with California, too.
In 2015, after experiencing a measles outbreak linked to Disneyland that sickened nearly 160 people, California removed the personal and religious exemptions. The state legislature is considering whether to tighten rules around medical exemptions after the number of children entering kindergarten with them tripled since the law passed in 2015.
According to the Association of State and Territorial Health Officials, other states pondering getting rid of the personal exemption include Arizona, Iowa, Maine, Minnesota, New Jersey, New York and Oregon. Four of those seven – Arizona, New Jersey, New York and Oregon – have had measles cases this year.
On the other hand, several states are debating bills to expand or protect exemptions, illustrating the issue’s complexity and the strong feelings on both sides of it.
Hundreds of Washingtonians protested HB 1638 in front of the state Capitol in February, and public health practitioners such as Levine fear their voices are getting drowned out by a cacophony of misinformed – or ill-intentioned – vaccine opponents using social media and even bots to spread their message.
The long-debunked myth that vaccines are linked to autism continues to be disseminated, as does the notion that they’re dangerous even when studies prove otherwise and agencies such as the Centers for Disease Control and Prevention vouch for their safety.
Adverse reactions do occur, experts say, but they’re rare and usually mild, like a rash or fever.
Still, organizations such as the National Vaccine Information Center can give the impression that parents risk their kids’ lives by getting them vaccinated.
President Barbara Loe Fisher said the NVIC, which she co-founded in 1982 under the name Dissatisfied Parents Together, merely advocates informed consent and does not make recommendations related to immunizations.
Asked about the government’s duty to protect its citizens through public health policy, Fisher said, “Are you saying that a public health law that requires a certain minority of individuals to risk their lives, sacrifice their lives, for the rest is a moral law when they’re not given the choice of whether or not they’re going to participate in that sacrifice? That’s not a moral public health law.’’
By the numbers
The precise number of deaths linked to immunizations in the USA is hard to pin down, but the CDC said life-threatening allergic reactions to a substance in a vaccine occur about once every million doses.
There have been 1,295 claims filed for death since the National Vaccine Injury Compensation Program was established in 1986 as a no-fault option to litigation. About 54% of those claims were for the DTP vaccine (diphtheria, tetanus, pertussis), which was replaced in the 1990s by the safer DTaP.
That leaves 599 death claims for other vaccines, 55% of which were dismissed, leaving about 270 of the death claims to have possibly been the result of vaccines. That comes out to about nine a year since 1986, considerably lower than the number of annual deaths due to peanut allergy (75 to 125) or stings by bees, wasps or hornets (89 in 2017).
Fisher pointed out that more than $4 billion has been paid out by the compensation program. According to CDC figures, 3.4 billion doses of covered vaccines were distributed in the USA from 2006 to 2017, and 4,250 compensated claims were adjudicated. That comes out to 1.25 paid claims for every million doses.
Nevertheless, Fisher said the anti-vaccine movement will continue to grow, and she sees it as part of a fight for civil liberties.
“Today, everybody knows somebody who was healthy, got vaccinated and was never healthy again,’’ she said, “and that’s the reason this issue is not going to go away no matter what kind of laws and no matter what kind of censorship is applied.’’
Nate Smith, director of the Arkansas Department of Health, is among the NVIC’s many critics, calling it “an anti-vaccination group." Part of what makes such organizations dangerous, he said, is that they can appear to provide legitimate information.
“Sometimes, they present things in ways that are very reasonable, but then other times, they make statements that are patently false,’’ Smith said. “So it’s very difficult for someone who doesn’t have a background in vaccination science or in public health to discern.’’
Like other health officials, Smith acknowledged vaccines are not 100% safe or effective. They come with minor risks, he said, which are minimized by administering the shots in settings where a reaction can be managed quickly, such as a medical facility.
Moreover, inoculation certainly beats the alternative.
Before the measles vaccine program was introduced in 1963, 3 million to 4 million Americans contracted the illness every year, and about 400 to 500 died. The MMR vaccine reduced the disease’s rate by 99%, and measles was declared eliminated in 2000.
The impact of vaccines
Measles is still a scourge in other parts of the globe, killing 110,000 in 2017, mostly children under 5, the World Health Organization said.
The disease is transmitted through droplets from the nose, mouth or throat of an infected person, and the virus can linger in the air or surfaces for up to two hours, spreading to 90% of people who are not immune and are exposed to someone with measles.
Vaccines have made a major dent, preventing about 21.1 million deaths from 2000 to 2017, according to the WHO, which pointed to an increase in child inoculation rates from 72% to 85% as the reason.
That’s why medical practitioners are so adamant about the importance of the MMR shot, despite the possible side effects.
“Allergic reactions can occur to any medication, any food, any substance the body comes in contact with,’’ Smith said. “Obviously, if we tried to avoid any possibility of an allergic reaction, we would stop using any medication and stop eating any food, and we wouldn’t go outside because we could get in contact with an insect."
Smith said he recognizes the political climate in every state – vaccine policy is not determined at the federal level – plays a significant role in what laws are enacted regarding inoculations.
There have been no reported cases of measles in Arkansas this year, he said, so momentum has not built to remove the state’s philosophical and religious exemptions.
Surveying the national landscape, Smith, Levine and their colleagues expressed concern that it’s not just infected travelers coming into the country who present a danger but also the growing communities of unvaccinated people who helped breach the wall of protection immunization provided.
What would happen if states opted to make vaccines voluntary instead of mandatory?
“I think the answer to that has revealed itself already with this epidemic of measles," Levine said. “If you allow populations to get below the level required for herd immunity and you allow them to get to low enough levels of vaccine, then because the rest of the world still has plenty of active measles, any case can come in and take over in a population."
This article originally appeared on USA TODAY: There are nearly 400 reported cases of measles in the USA. What are states doing about it?