Nonmedical vaccine exemptions for measles need to be eliminated across the U.S.

The near-loss of America's measles elimination status in 2019 should serve as a wake-up call for all of us.
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By Tara C. Smith, professor of epidemiology at Kent State University

The year was 1992. Bill Clinton was elected president of the United States. Compact discs overtook cassette tapes as the preferred way to play music. “Achy Breaky Heart” and “November Rain” were in heavy rotation on the radio. And it was the last year the country recorded more measles cases than we have so far in 2019. As of Oct. 3, the Centers for Disease Control and Prevention has confirmed 1,250 cases.

From 1989-91, the country experienced the worst measles outbreak since the measles vaccine came into widespread use in the 1960s. Over 55,000 cases and 166 deaths were identified during the epidemic. The outbreak led to a rapid change in vaccine policy, as physicians and researchers realized that a single dose of the measles, mumps and rubella vaccine (MMR) was not sufficient to protect a high enough proportion of the population to prevent widespread measles transmission.

With the resurgence of measles, it’s time for another policy change: eliminate nonmedical exemptions to vaccinations for school entry, across the board.

Consequently, a second MMR dose was added to the childhood vaccination schedule; currently, children get the first dose at a year old and the second typically around age 4. With the resurgence of measles, it’s time for another policy change: eliminate nonmedical exemptions to vaccinations for school entry, across the board.

The addition of a second MMR vaccine dose eventually led to the elimination of endemic measles transmission in the U.S. in 2000, meaning that every outbreak we’ve seen since that year has been the result of an imported case of measles infection. In 2019, an outbreak in Washington state started when an infected traveler returned from Ukraine. In Rockland County, New York, a traveler from Israel returned to New York and started an outbreak that began in October 2018. Both Ukraine and Israel are currently experiencing measles outbreaks.

What stopped each U.S. outbreak was a combination of quarantines for exposed individuals, isolation for sick patients and massive vaccination campaigns designed to inoculate individuals who may lack immunity. The Washington state outbreak was halted in late April, after 71 cases. The cost to Clark County, Washington, alone was $864,679, with the bulk of that due to the 12,684 hours public health staff spent on investigating the epidemic. New York City spent $6 million on personnel and educational materials to stem its own outbreak, centered in Brooklyn, where 649 cases were confirmed in 2018-19.

America needs to stop playing whack-a-mole with measles outbreaks. Instead, we need to reduce the pools of susceptible individuals. Collectively, 95 percent of the 312 individuals infected during the Rockland County outbreak were unvaccinated, undervaccinated or had an unknown vaccine status, according to the Rockland County Department of Health The numbers were almost identical in Clark County, Washington, where 96 percent of the cases (68 of 71 individuals) were unvaccinated or had an unknown vaccine status.

There is little doubt that undervaccinated populations serve as tinder for outbreaks of vaccine-preventable diseases. Recent research examining areas in Texas with low vaccination rates has demonstrated that several metro areas in the state, including Austin and Dallas, are ripe for outbreaks that could result in up to 400 measles cases each. And it’s not just Texas. “Hotspots” for disease transmission were identified throughout the country in a 2018 study conducted by researchers at Baylor College of Medicine in Houston, examining areas where nonmedical vaccine exemptions were high and vaccination rates were low.

Following its 2015 measles outbreak, linked to Disneyland and resulting in 147 measles cases, California tightened its vaccine exemptions for schoolchildren. California had previously allowed personal belief and medical exemptions to vaccination. After the passage of a state law in 2015, only medical exemptions remained. At the time, only West Virginia and Mississippi had similar policies. This year, New York and Maine passed similar laws. Washington state modified its law for the MMR vaccine only, removing personal and philosophical belief exemptions.

Because legislation regarding school vaccine requirements are a state matter, it would be difficult to enact such a policy federally. Some have laid out roadmaps for such an undertaking, but federal support is unlikely. Therefore, the further removal of vaccine exemptions will be up to the remaining 45 states that allow nonmedical exemptions. Legislation was proposed this year in several states, but failed for various reasons — notably in Oregon, where the governor used the death of the bill as a bargaining chip to lure Republicans back to work after a walkout.

And even in states that are considered vaccine success stories, state legislators can become targets of the small but vocal antivaccine movement.

And even in states that are considered vaccine success stories, state legislators can become targets of the small but vocal antivaccine movement. Dr. Richard Pan, a pediatrician and state senator in California who led the fight to eliminate nonmedical vaccine exemptions in the state, was recently physically assaulted for his advocacy. Weeks later, an antivaccine activist threw menstrual blood at California legislators while they were in session.

As uncomfortable as it might be to fight for the removal of vaccine exemptions, it is advocacy that we need right now. Due to the outbreak in New York, which began on Oct. 1, 2018, and officially ended on Sept. 25, the U.S. was in danger of losing its measles elimination status conferred by the World Health Organization. This status is rescinded if transmission within a country exceeds one year — and we were just a week shy of that dreaded milestone. Other countries, including the U.K., Greece, Venezuela and Brazil all lost their elimination status within the last year, which globally has been one of the worst measles years since 2006.

We know that school vaccination is one way to reduce the number of unvaccinated individuals, and therefore protect the country at large. And while the loud voices of antivaccine campaigners can make such laws seem unfavorable, polling data show otherwise. A second bill passed in California this year, SB276, which strengthened medical exemptions after some parents used fraudulent medical exemptions to avoid vaccination and get around the changes implemented via SB277. A Los Angeles Times poll showed that over 80 percent of the population surveyed supported the bill, and that support was bipartisan.

Finally, though the removal of vaccine exemptions is not without controversy, both the American Medical Association and the American Academy of Pediatrics support tightening vaccine exemptions for U.S. schoolchildren as a measure to improve vaccination rates and reduce the circulation of vaccine-preventable diseases in the population.

The near-loss of the country’s measles elimination status should serve as a wake-up call for all of us. America has been a global leader in infectious disease control, but this year we’ve teetered on the verge of a massive blow to our reputation and credibility on the world stage. Meanwhile, 1,250 individuals and counting — primarily children — suffered from measles infection unnecessarily. We need to do better, and removing vaccine exemptions is a key way to protect the health of our most vulnerable.