An ongoing dialogue on HIV/AIDS, infectious diseases,
February 10th, 2019
Six Musings Triggered by the Latest Measles Outbreak
Source: CDC
In 2018, there were 372 cases of measles in the United States, the largest number since 2014. This year, we’ve already had 79 cases, many from a large outbreak in the Pacific Northwest — where anti-vaccine proponents recently protested efforts to restrict nonmedical vaccine exemptions.
A few ruminations triggered by this outbreak.
1. The vaccine is extraordinarily effective at preventing measles, lulling us into a false sense of security. After many years of clinical practice, the total number of measles cases seen by my wife (a pediatrician) and me (an infectious diseases specialist) is … two. We’ve both seen one.
The measles vaccine is wonderfully effective — think how contagious it is! — but the net result is that most clinicians in the United States have never seen a case. Here, take a look at this poll:
Simple poll for you ID and non-ID clinicians out there. If you answer Yes to the question, please help by providing the context (when it was, where it was, why it happened, etc).
Have you seen a case of measles in the post-measles vaccine era?— Paul Sax (@PaulSaxMD) February 10, 2019
Around three-quarters of the clinicians have never seen a single case. If the poll had been limited to US doctors and nurses, even more would have no personal contact with the disease. Non-clinicians, of course, have even less direct experience.
The effectiveness of the vaccine indirectly fuels some of the vaccine refusers — it’s the victim of its own success. Some may not believe it’s a serious disease since they’ve never seen it. Others might think it’s too rare to cause their child a problem, so why vaccinate? (More on this latter ungenerous line of thinking below.)
Both views are terribly short-sighted. Regular readers of this blog will undoubtedly agree, but how can we overcome this?
2. The anti-vaccine effort spans the entire political, economic, religious, and racial spectrum. Rich and poor; left, right, center; observant, agnostic, atheist — does not seem to matter.
We’ve got celebrity “experts” such as Jenny McCarthy and Jim Carrey; “environmentalist” and lawyer Robert F. Kennedy Jr who, since he’s related to a former president, gets tons of attention; a Hasidic Jewish community in Brooklyn; immigrants from Somalia in Minnesota. There are people up and down the socioeconomic spectrum who just don’t trust either the science, or the government, or both.
Homeopaths and crystal lovers might be leery of — some would say paranoid about — hidden toxins, chemicals, and preservatives in vaccines. They prefer “natural” immunity to the vaccine-induced kind, nevermind that measles itself can be fatal.
Libertarians want the government out of their health care choices, period. Recent immigrants might be susceptible to persuasive anti-science hucksters — this is what happened in Minnesota.
How does one target educational efforts about the importance of immunizations to such a diverse group?
3. The cost of childhood immunizations is no impediment to receiving them. Our fragmented US healthcare system definitely gets this one right — childhood immunizations are covered essentially everywhere, regardless of a family’s ability to pay.
Why might this be? Child immunizations do it all — they are highly effective in preventing illness and death, very safe, reasonably priced, and actually save our society money. Does anything else we do in medicine have such strong personal, public health, and economic data supporting their use?
4. Eliminating nonmedical vaccine exemptions is absolutely critical for maintaining herd immunity. Several years ago, I interviewed Dr. Samuel Katz, a physician-scientist who played a critical role in developing the measles vaccine. (Transcript here, podcast here at the bottom of the page.)
After he provided an overview of the discovery of the attenuated measles virus strain and the early clinical trials, I asked him to comment on on the anti-vaccine movement. To my surprise, he was relatively sympathetic, calling the group “vaccine hesitant” rather than “vaccine refusers.”
(I confess to being much less charitable, viewing parents who refuse vaccines for their children for nonmedical reasons as exhibiting an extreme form of selfishness and antisocial behavior that borders on criminal.)
However, on one fact he was quite clear — the critical role of vaccine school-entry requirements in keeping measles at bay. These regulations are much stronger here than in most of Europe, and as a result, Europe’s measles outbreaks are far worse. In 2018 alone, Europe had over 82,000 cases and 72 deaths — three times the number of cases they had in 2017, and over 200 times the number of cases here.
As for religious exemptions, there’s a good chance many (most? all?) reflect personal beliefs, not something specifically forbidden by a religion. Where does it state in the Bible, the Torah, the Koran, or in any religious text that vaccines are prohibited? And why should religious exemptions be permitted for vaccines, and not other safety codes and laws? As noted in this excellent editorial in The Boston Globe, “There’s no religious exemption from the fire code or the seat-belt law.”
5. Many people refuse the vaccine for their kids because they just want a free ride. I imagine the thinking goes like this:
Hey, if everyone else gets vaccinated, then measles will be so uncommon that my kid won’t need it. And I heard from my yoga instructor that this is what she did, and her kid has been fine — so that’s what we’re doing too.
You want proof? Vaccine demand is up 500% in the county experiencing the outbreak.
Guess it doesn’t take much to overcome those “philosophical” or “religious” objections to the measles vaccine! For more on this line of selfish and privileged thinking, read this superb post by Dr. Amy Tuteur, who writes:
Nothing says “privilege” quite like refusing the same vaccines that an impoverished mother in a developing country would trudge five miles to get for her child. No sooner did the privilege disappear — destroyed by anti-vaxxers themselves whose choices have ushered back a deadly public scourge — then the anti-vaxxers folded.
6. Many stock photos of vaccine administration are absolutely terrible. How many times have you read a piece online or in a magazine that shows a giant needle and a crying kid? Sometimes there’s also a scary-looking doctor or nurse.
Seth Mnookin, Professor of Comparative Media Studies/Writing at MIT, wrote an excellent book on the vaccine controversy. He also provided this choice example of bad vaccine images in the media:
Worst possible art choice for this @slate piece about understanding root of vaccine fears. Pictures of needles going into babies make people anxious & uncomfortable. Regartdless of content of article, yr using anti-vaccine propoganda to illustrate it. https://t.co/KRuvEU5HBW
— Seth Mnookin (@sethmnookin) February 5, 2019
I agree entirely that far better would be to show pictures of happy, measles-free children, or parents with kids visiting a friendly-looking doctor’s office — or at least anything else besides a little kid and a big needle!
As for the outbreak in Washington, I am hopeful that the surge in immunizations will get the new infections quickly under control.
After all, it doesn’t matter why you immunize your kids — it just matters that you do it.
Herd immunity in one minute — remember, we need at least 90% immunized for it to work for measles!
28 Responses to “Six Musings Triggered by the Latest Measles Outbreak”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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Unfortunately, it’s not only the non-medical exemptions that we have to worry about. After California strengthened its vaccination laws, parents are now finding physicians willing to write medical exemptions for a fee.
What if we require that unvaccinated children be home schooled and get their medical care only in quarantined areas of emergency rooms? And of course, don’t even THINK about Disney World, movie theaters, or Chuck E. Cheese! We could make it do burdensome that only the most fanatical of parents would stick with it.
i would report any parent whose child contracts a vaccine preventable disease to child protection services. most of my office patients are on suboxone and their treatment contract clearly states that their children get all the appplicable vaccines. it also states that they get a yearly flu vaccine and an hbv vaccine if h/o ivdu or have hcv or hiv. they all sign for their flu shots and i get alot of complaints and grumbles. unfortuneately, i have no way to know that their kids are vaccinated, i’m not even allowed by nys law to vaccinate them as i do not see kids routinely and therefore have the required state paperwork.
“Does anything else we do in medicine have such strong personal, public health, and economic data supporting their use?”
Sorry I have to defend my own focus of attention somewhat: bending over backwards to assist in the prevention of unintended pregnancies.
The increased worldwide use of modern contraception for postponing, spacing and limiting, was in itself the most important single factor the last 60 years in reducing the mortality of mothers and their children and it prevented many wars and much misery related to dwindling resources.
Thomas Malthus apocalyptic expectations, made more likely because of the successes of vaccinations and the development of antibiotics are kept more or less at bay by modern contraceptives.
D.A.A. Verkuyl FRCOG, The Netherlands, worked also 24 years in Africa
I should have added that I saw many serious cases of measles as a district doctor in sub-Saharan Africa, including Cancrum oris (Noma).
Interesting that many of the same crowd who would be “hurt” by the picture of a needle going into a baby’s arm are not at all offended by killing a baby per a mother’s desire for abortion.
Really, really off topic!
Not off topic if the topic is life …whether death from measles is prevented or whether death from abortion is prevented.
Recent research shows that video presentation of the actual disease was far more convincing than anything else. We should focus our efforts there and include footage of a wide variety of ethnic groups.
I interned in ’60, b4 measles vaccine. Saw many cases. After the vaccine was in wide use, mostly suspected modified measles.
I couldn’t agree more with this blog post.
Although I hate to say it, may be the threat of litigation would be enough to get parents to get their child immunized. For example, let’s say little Johnny doesn’t get immunized because Mom & Dad are afraid because of all the “Fake News” they heard about the vaccine. Let’s say Johnny gets measles but then passes it on to little Sarah. However, little Sarah gets one of the rare but serious complications of measles such as measles encephalitis or measles pneumonia, which causes her to be critically ill, or perhaps even die. Who is at fault here? Do the parents who didn’t get their child immunized have some culpability? How about the person(s) who originated the information that the MMR is bad?
As a resident, we had an immune-compromised child die of measles “pneumonia”. This is why enough people need to be immunized to have “herd immunity”. 75% of the population doesn’t cut it!
I wonder if one could leverage the insurance companies a bit. Higher premiums for non-vaccinator? Or refusal to pay for medical treatment for a vaccine-preventable illness?
Given that not vaccinating a child imposes a number of costs upon our society (administering exemptions; managing outbreaks; exposing truly medically non-vaccinable people to potentially lethal illness), perhaps we ought to be taxing non-vaccinating families to cover the burden.
We don’t have a problem with measles in Mississippi.
The one and only time I saw measles was in 1990-91 in Saudi Arabia. A young healthy military recruit had slipped through the vaccination program and died of measles pneumonia. So sad!
Here’s a thought: ‘Germs are not a real thing’: Fox News host says he hasn’t washed hands in 10 years –
– headline at https://www.theguardian.com/media/2019/feb/11/germs-are-not-real-fox-news-host-pete-hegseth
Germs are not a real thing, so measles probably isn’t either …..
I have wondered how this ant-vax community would react to their 3 yo being bit by a known rabid animal where the sucess ratio of the rabies vaccine /RIG is essentially 100% and the consequences of refusing the vaccine is virtually 100% fatal…
Also, Mississippi has the highest immunization rates because there is no exemption except for medical exemptions- there was a state court decision in that state.
I had measles encephalitis in the 1940s at age 7, well before the vaccine. I was hospitalized in isolation for 10 days. Another boy on the next block died of it. You can imagine how thankful I was that there was a vaccine available for my own children and other family little ones.
The counter-campaign needs to come now: show pictures of suffering children with ex anthems, enanthems, pneumonitis, etc. Give the illness a face, because people hold untenable abstract positions out of sheer ignorance.
The vaccine is ~95% efficacy. If we reach 95% vaccine rate of uptake, only 95% of this 95% will seroconvert,That makes 90.25%. Mathematical modellers say that we need 96% immunity rate for elimination – with a 95% efficacy vaccine. This is also what we are up against with measles.
With respect to the religious angle, I can only speak for Jewish law. There is nothing there prohibiting or even discouraging vaccination; the reality is quite the opposite because of the obligation to preserve life. Unfortunately, the communities involved have been infiltrated by anti-vaccine thinking. While some of leaders have used religious rhetoric in denouncing vaccination, the opposition to vaccination is based on standard anti-vaccine concepts from the usual sources, not religious law. Unfortunately, if these concepts are espoused by leaders in the community, they have great influence. This makes public health outreach to these communities particularly challenging.
When talking to vaccine refusers, I ask them to go to this website of the personal testimonies of parents who regret not vaccinating their kids: http://www.vaccineinformation.org/infants-children/testimonies/
Hi – Could someone please address the science evaluating the side effects of the MMR vaccine compared to the side effects of contracting measles itself? Physicians for Informed Consent.org has a number of citation-supported assertions regarding the serious adverse effects that may follow from the MMR vaccine. For example, “Common side effects of the MMR vaccine include fever,
mild rash, and swelling of glands in the cheeks or neck. A
more serious side effect is seizure, which occurs in about 1 in 640 children vaccinated with MMR—about five times more often than seizure from measles infection.” The physicians in favor of informed consent also suggest that the death rate from the MMR vaccine may be higher than that from contracting the disease itself.
Surely such claims by doctors and scientists are as likely to be on the minds of parents as recommendations from “yoga instructors.” Rather than dismissively labeling concerned parents as “selfish” or “borderline criminal” or superstitious or what have you, it might be helpful to methodically address the science related to serious adverse outcomes. It might also be helpful to actually speak with some of the concerned parents, gathering some empirical data rather than mere imaginings about what might be on their minds.
Similarly, the suggestion embedded in item 6 that better medical marketing makes for more receptivity to vaccines may be true, but it might also be true that a focus on marketing repels concerned parents who view the campaign in favor of mandatory universal vaccination as lacking in scientific circumspection and full risk disclosure. My bet would be that more forthright, well supported information – rather than better glossy images – is what many concerned parents would want.
I had the mumps, measels, chickpox etc. and then mandated the MMR and HepB for titters of rubella and HepB. Chronically ill ever since the jab. Ruined my life. Many people are saying the same and many doctors and vets have concurred that vaccines are not good for all.
Many adults are running around the us w/o titters to measels etc too. I wouldn’t doubt if many people who write on here are not immune to measels
By the way. It’s worth pointing out that being vaccinated DOES NOT mean you won’t get a virus or disease. A good portion of people who get x, y, z disease have already been vaccinated. As a quick example, in 2016 there were 86 cases of measles. 26% of those cases were fully vaccinated individuals. 18% had unknown vaccination history. (https://www.cdc.gov/measles/downloads/measlesdataandstatsslideset.pdf). No one died that year. ALL 86 of those people are now 100% immune for the rest of their life and never need another measles vaccine.
“Anti-vaccine” isn’t as cut and dry as you make it out to be. It is my choice to be educated and refuse vaccination. If a woman can choose to terminate a pregnancy, why can’t I choose if I want to be vaccinated?
Can anyone show me ONE scientific study where the vaccines have been proven to induce “herd immunity”? Rather than the diseases themselves? All I see is that A.W. Heidrich tested if enough children getting ACTUAL MEASLES would promote “herd immunity” and it did. It seems vaccinologists are just taking wrongful credit. I’ll be waiting for the science on VACCINE TESTED “herd immunity.”
Thanks Daniel. One of healthcare ethics according to (Idziak, 2016) (written by Janine Idziak, PhD) would be autonomy. People get to choose what they are comfortable with for their bodies. You simply can’t forcibly inject people. It’s not ethical.
Thank you for this! People need to have more awareness of what they are causing my not getting there shots. There are so many proven studies that show that people getting measles from vaccinations is ridiculous, People need to get their children there shots from hospitals! if you don’t trust your local doctors go to some of the best hospitals. I usually refer to the women’s choice award list but there are so many out there!