(My first column on the problem of non-medical exemptions to immunization requirements [Mt. Vernon Gazette 3-28-19] identified the role immunizations play in limiting vaccine-preventable diseases and underscored the threat posed by vaccine hesitancy/refusal to the public’s health.)
Measles is back and it grips our nation, with 28 states reporting 1,044 cases — a 27 year high! Cases recently were confirmed in Maryland and here in Virginia. The Virginia case involved a traveller passing through Dulles Airport. It’s hard to believe but America eliminated measles in 2000 with an aggressive, government-sponsored immunization campaign, however that landmark public health achievement will be history if the outbreaks continue through Sept. 30. The Centers for Disease Control and Prevention (CDC) define a measles outbreak as >3 cases/100K population/month. For Mt. Vernon, that’s about one case every three months. Seven states, including Maryland, New York, and Pennsylvania, report 15 recent outbreaks.
Measles is highly contagious. It survives – in the air and on surfaces – for two hours. Infected persons are contagious for days – before they feel sick and after they feel well. A non-immune person has up to 90 percent chance of contracting measles after exposure.
Measles remains a major cause of death and disability globally, killing approximately 110,000 in 2017. Five percent of those infected will develop pneumonia and 0.1 percent, encephalitis. Case severity is unpredictable. Survivors risk deafness, blindness and intellectual disability. Greater healthcare resources have improved our outcomes, but we pay a big price: school absence; work disruption; and danger for vulnerable community members, e.g. infants, pregnant women, the elderly, and those immunosuppressed. Public health response is costly —outbreak control in the state of Washington required identification and evaluation of 4,100 exposures, costing $1.9 million.
Treatment is a costly and time-consuming response to a problem that should not have occurred in the first place. These illnesses are easily preventable with available vaccines in doctor’s offices and clinics. Between 2000-2017, immunization programs reduced global measles deaths 80 percent, saving over two million children’s lives under five years old, at a cost of only $1 a day!
The American epidemic is caused by vulnerable travelers, exposed to measles abroad, and then making contact with under-immunized communities here. We should focus on the latter factor. Populations at risk often reside in isolated, insular communities, e.g. Somalis in Minnesota and ultra-Orthodox Jews in New York and Maryland; however, well-educated, “mainstream” communities are at risk too. All are susceptible to sophisticated, factually inaccurate, anti-vaccine information widely available via social media, intentionally targeted by “anti-vaxxers.”
To be sure, not everyone should be immunized, e.g. persons allergic to the vaccine or those immunosuppressed. Nevertheless, they will be protected from measles if there is sufficient “herd immunity” – which is 96 percent resistance within the community conferred by immunizations. A medical exemption is the only one based in science.
Every state requires immunizations for school attendance, but 47 states grant exemptions for religious reasons and 18 for personal beliefs. Virginia (Code of VA §32.1-46) grants religious exemptions, even though most faiths support immunizations, and allows philosophical exemption for HPV vaccine. The CDC reports steady increase in unvaccinated children — 1.3 percent in 2015 vs. 0.3 percent in 2001 — leaving 100,000 unprotected against 14 vaccine preventable diseases. This parallels a rise in non-medical exemptions — currently, 2.2 percent. Public health officials identify non-medical exemptions as the “vehicle” driving vaccine refusals.
We have a good record of safe, effective measles and other vaccination programs. We are obligated to safeguard our communities from vaccine-preventable diseases. It is essential to maintain herd immunity. The best way to do that is to immunize everyone not medically exempt.