History
Of The anti-Vaccination Movement
Religious
arguments against inoculation were advanced even before the work of Edward Jenner (pioneer of the
smallpox
vaccine);
for example, in a 1722 sermon entitled "The Dangerous and Sinful Practice
of Inoculation" the English theologian Rev. Edward Massey argued that
diseases are sent by God to punish sin and that any attempt to prevent smallpox
via inoculation is a "diabolical operation". Some
anti-vaccinationists still base their stance against vaccination with reference
to their religious beliefs.
After
Jenner's work, vaccination became widespread in the United Kingdom in the early
1800s. Variolation, which had
preceded vaccination, was banned in 1840 because of its greater risks. Public
policy and successive Vaccination
Acts
first encouraged vaccination and then made it mandatory for all infants in
1853, with the highest penalty for refusal being a prison sentence. This was a
significant change in the relationship between the British state and its
citizens, and there was a public backlash. After an 1867 law extended the
requirement to age 14 years, its opponents focused concern on infringement of
individual freedom, and eventually a 1898 law allowed for conscientious
objection to compulsory vaccination.
In
the 19th century, the city of Leicester in the UK
achieved a high level of isolation of smallpox cases and great reduction in
spread compared to other areas. The mainstay of Leicester's approach to
conquering smallpox was to decline vaccination and put their public funds into
sanitary improvements. Bigg's account of the public health procedures in
Leicester, presented as evidence to the Royal Commission, refers to erysipelas, an infection
of the superficial tissues which was a complication of any surgical procedure.
In
the U.S., President Thomas Jefferson took a close
interest in vaccination, alongside Dr. Waterhouse, chief physician at Boston.
Jefferson encouraged the development of ways to transport vaccine material
through the Southern states, which included measures to avoid damage by heat, a
leading cause of ineffective batches. Smallpox outbreaks were
contained by the latter half of the 19th century, a development widely attributed
to vaccination of a large portion of the population. Vaccination rates fell
after this decline in smallpox cases, and the disease again became epidemic in
the 1870s (see smallpox).
Anti-vaccination
activity increased again in the U.S. in the late 19th century. After a visit to
New York in 1879 by William
Tebb,
a prominent British anti-vaccinationist, the Anti-Vaccination Society of
America was founded. The New England Anti-Compulsory Vaccination League was
formed in 1882, and the Anti-Vaccination League of New York City in 1885.
John
Pitcairn,
the wealthy founder of the Pittsburgh Plate Glass Company (now PPG Industries) emerged as a
major financer and leader of the American anti-vaccination movement. On March
5, 1907, in Harrisburg, Pennsylvania, he delivered an address to the Committee
on Public Health and Sanitation of the Pennsylvania
General Assembly
criticizing vaccination. He later sponsored the National Anti-Vaccination
Conference, which, held in Philadelphia on October, 1908, led to the creation
of The
Anti-Vaccination League of America. When the League was organized later
that month, Pitcairn was chosen to be its first president. On December 1, 1911,
he was appointed by Pennsylvania Governor John K. Tener to the Pennsylvania
State Vaccination Commission, and subsequently authored a detailed
report strongly opposing the Commission's conclusions. He continued to be a
staunch opponent of vaccination until his death in 1916.
In
November 1904, in response to years of inadequate sanitation and disease,
followed by a poorly-explained public health campaign led by the renowned
Brazilian public health official Oswaldo Cruz, citizens and
military cadets in Rio
de Janeiro
arose in a Revolta da Vacina or Vaccine Revolt. Riots broke
out on the day a vaccination law took effect; vaccination symbolized the most
feared and most tangible aspect of a public health plan that included other
features such as urban renewal that many had opposed for years.
In
the early 19th century, the anti-vaccination movement drew members from across
a wide range of society; more recently, it has been reduced to a predominantly
middle-class phenomenon. Arguments against vaccines in the 21st century are
often similar to those of 19th-century anti-vaccinationists.
The
idea that vaccines, and specifically the Measles/Mumps/Rubella vaccine, causes
autism was first proposed by Andrew Wakefield. He was the
lead author of a controversial 1998 research study, published in The Lancet, which reported
bowel symptoms in a prospective case series of twelve
consecutive vaccinated children
diagnosed with autism
spectrum
disorders and other disabilities, and alleged a possible connection with the MMR vaccination. Citing safety
concerns, in a press conference held in conjunction with the release of the
report, Wakefield recommended separating the components of the injections by at
least a year. Given the widespread media coverage of Wakefield's claims, his
recommendation was deemed responsible for a decrease in immunization rates in the
UK. The section of the paper setting out its conclusions was subsequently retracted
by ten of the paper's thirteen authors.
Following
the controversy, in March, 2004, the British General
Medical Council
(GMC) announced it was launching an inquiry into allegations of serious professional
misconduct
against Wakefield and two former colleagues. It centered on claims, brought
forth by journalist Brian
Deer,
that autistic and neurotypical children may
have been subjected to unnecessary lumbar punctures and colon biopsies,
including one colonoscopy that caused the child life-threatening perforations
of the bowel. Additionally, Wakefield is accused by the GMC of suppressing and
falsifying data based on the testimony of Dr. Stephen Bustin and Dr. Nicholas
Chadwick during the Autism
Omnibus vaccine hearing in June, 2007.
In
February 2009, The Sunday Times reported that a further investigation by the
newspaper had revealed that Wakefield "changed and misreported results in
his research, creating the appearance of a possible link with autism",
citing evidence obtained by the newspaper from medical records and interviews
with witnesses, and supported by evidence presented to the GMC. The newspaper
went on to state that the rates of inoculation fell from 92% (very slightly
below measles herd immunity) to below 80%
after the publication of Wakefield's study, and that confirmed cases of measles
in England and Wales have risen from 56 in 1998 to 1348 in 2008, with two child
fatalities.
In
May 2010, the British General Medical Council investigation concluded that
Wakefield and his two colleagues, Professor Walker-Smith and Professor Murch,
had engaged in serious
medical misconduct
concerning the 1998 study and Wakefield’s license to practice medicine in the
UK was revoked.
In
January 2011, the British Medical
Journal
found that Andrew Wakefield had participated in intentional fraud concerning his
work which led to the 1998 paper that linked the MMR Vaccine to Autism. The BMJ
published three articles by journalist Brian Deer that detailed how the fraud
was conducted entitled “Secrets of the MMR Scare” Part 1, Part 2 and Part 3. In November
2011, the BMJ published another article entitled “More Secrets of the
MMR Scare”.
Links
To Disease Outbreaks Due To Anti-Vaccination Beliefs:
CDC
Preventable Measles Among U.S. Residents, 2001--2004: “her parents
had declined to have her vaccinated for religious beliefs.”
CDC
Import-Associated Measles Outbreak --- Indiana, May--June 2005: “Persons
choosing a nonmedical exemption from vaccination are approximately 22 times
more likely to acquire measles than persons who are vaccinated. Parents and
persons who opt out of vaccination should be aware of the risk that this
practice places upon their children and their community. Communities of persons
who have not been vaccinated can make intensive measles-containment activities
necessary.”
CDC
Measles --- United States, 2004: “One case of secondary spread was
identified in a California resident aged 19 years with a nonmedical exemption
for measles vaccination who had had close contact with one of the adoptees. In
the second outbreak, a U.S. student aged 19 years with a nonmedical exemption
for measles vaccination was infected in India and returned to Iowa, where two
secondary cases occurred.”
CDC
Varicella Outbreak Among Vaccinated Children --- Nebraska, 2004: “No parents of
susceptible students agreed to administration of varicella vaccine to their
children during the outbreak, likely because of a widespread belief among the
parents that the vaccine was ineffective; the outbreak coincided with
introduction of the varicella vaccination requirement, and some vaccinated
students were contracting varicella. This report refutes the misconception that
vaccination was ineffective and underscores the importance of investigating
such outbreaks and educating parents about the value of varicella vaccination.”
CDC
Measles --- United States, 2005: “28 (88%) patients aged 1--19 years
had not been vaccinated, primarily because their parents were concerned about
potential adverse events associated with vaccination. The outbreak occurred
because measles was imported into a population of children whose parents had
chosen not to vaccinate their children because of safety concerns, despite
evidence that that measles-containing vaccine is safe and effective. A major
epidemic was averted because of high vaccination levels and a low rate of
vaccine failure in the surrounding community. The cost of containing this
outbreak was estimated at $167,685. This outbreak and other cases reported
during 2005 likely could have been prevented had existing ACIP vaccination
recommendations been followed. The index case traveler should have been
vaccinated with 2 doses of measles-containing vaccine before departure; exposed
school-age children and personnel working in health-care facilities also should
have had the recommended 2 doses before exposure.”
CDC
Outbreak of Measles --- San Diego, California, January--February 2008: “Measles
transmission in schools was common in the era before interruption of
endemic-disease transmission, and school requirements for vaccination have been
a successful strategy for achieving high vaccination coverage levels in this
age group and decreasing transmission in school settings. In the United States,
all states require children to be vaccinated in accordance with Advisory
Committee on Immunization Practices recommendations before attending school.
However, medical exemptions to immunization requirements for day care and
school attendance are available in all states; in addition, 48 states offer
nonmedical religious exemptions, and 21 states (including California) offer
nonmedical personal belief exemptions (PBEs). These exemptions are defined
differently by each state. The PBE allowed by California requires only a
parental affidavit. Compared with vaccinated persons, those exempt from
vaccination are 22 to 224 times more likely to contract measles.
CDC
Measles --- United States, January 1--April 25, 2008: “Many of the
measles cases in children in 2008 have occurred among children whose parents
claimed exemption from vaccination because of religious or personal beliefs and
in infants too young to be vaccinated. Forty-eight states currently allow
religious exemptions to school vaccination requirements, and 21 states allow
exemptions based on personal beliefs. During 2002 and 2003, nonmedical
exemption rates were higher in states that easily granted exemptions than
states with medium or difficult exemption processes; in such states, the
process of claiming a nonmedical exemption might require less effort than
fulfilling vaccination requirements. Although national vaccination levels are
high, unvaccinated children tend to be clustered geographically or socially,
increasing their risk for outbreaks. An upward trend in the mean proportion of
school children who were not vaccinated because of personal belief exemptions
was observed from 1991 to 2004. Increases in the proportion of persons
declining vaccination for themselves or their children might lead to large-scale
outbreaks in the United States, such as those that have occurred in other
countries (e.g., United Kingdom and Netherlands).”
CDC
Update: Measles --- United States, January--July 2008: “Washington,
April 2008: Because of their parents' philosophical or religious beliefs, none
of the 16 children had received measles-containing vaccine. Illinois, May 2008:
Because of their parents' beliefs against vaccination, none of the 25 had
received measles-containing vaccine.”
Mumps
Outbreak --- New York, New Jersey, Quebec, 2009: “The index
patient was a boy aged 11 years who had returned on June 17 from the United
Kingdom, where a mumps outbreak is ongoing with approximately 4,000 cases,
primarily in unvaccinated young adults in the general population.”
Hospital-Associated
Measles Outbreak — Pennsylvania, March–April 2009: “None of the
three secondarily infected children had been vaccinated for measles; the child
aged 11 months was too young for routine vaccination, and the index patient and
his brother were unvaccinated by parental choice.”
Notes
from the Field: Measles Transmission Associated with International Air Travel
--- Massachusetts and New York, July--August 2010: “On July 8,
2010, the Massachusetts Department of Public Health (MDPH) notified CDC of a
case of laboratory-confirmed measles in an unvaccinated airline passenger aged
23 months.”
Measles
Imported by Returning U.S. Travelers Aged 6--23 Months, January to February
2011:
“In the first 2 months of 2011, CDC received reports of seven imported measles
cases among returning U.S. travelers aged 6--23 months; four required
hospitalization. Young children are at greater risk for severe measles, death,
or sequelae such as subacute sclerosing panencephalitis. Although all seven
children had been eligible for vaccination before travel, none had received
measles, mumps, and rubella (MMR) vaccine.”
Notes
from the Field: Measles Outbreak --- Hennepin County, Minnesota,
February--March 2011:
“The patients included children aged 4 months--4 years and one adult aged 51
years; seven of the 13 were of Somali decent. Eight patients were hospitalized.
Vaccination status was known for 11 patients: five were too young to have been
vaccinated, and six (all of Somali descent) had not been vaccinated because of
parental concerns about the safety of the measles, mumps, and rubella (MMR)
vaccine.”
Measles
--- United States, January--May 20, 2011: “During 2001--2008, a median of
56 (range: 37--140) measles cases were reported to CDC annually; during the
first 19 weeks of 2011, 118 cases of measles were reported, the highest number
reported for this period since 1996. Of the 118 cases, 47 (40%) resulted in
hospitalization. Nine patients had pneumonia, but none had encephalitis and
none died. All but one hospitalized patient were unvaccinated.”
Notes
from the Field: Measles Outbreak --- Indiana, June--July 2011: “Of the 14
patients, 13 were unvaccinated persons in the same extended family. The
nonfamily member was a child aged 23 months who had received 1 dose of measles,
mumps, and rubella vaccine 4 months before illness onset. Four of the 14
patients were males; median age was 11.5 years (range: 15 months--27 years).
One patient was a woman in week 32 of pregnancy who was hospitalized for acute
pneumonitis. The index patient was an unvaccinated U.S. resident aged 24 years
who noted a rash on June 3 during a return flight from Indonesia, where measles
is endemic.“
Influenza-Associated
Pediatric Deaths --- United States, September 2010--August 2011: “These findings
underscore the importance of vaccinating children to prevent influenza virus
infection and its potentially severe complications. Health-care providers
should develop a comprehensive strategy to increase vaccination coverage among
children.”
Outbreak
of Meningococcal Disease Associated with an Elementary School — Oklahoma, March
2010:
“During March 10–31, 2010, the Oklahoma State Department of Health (OSDH)
investigated an outbreak of meningococcal (Neisseria meningitidis) disease
involving a consolidated school district of 1,850 students in rural
northeastern Oklahoma. Five cases of meningococcal disease (including one
probable case) were identified among four elementary school students and one
high school student. Two students died; two recovered fully, and one survivor
required amputation of all four limbs and facial reconstruction. None of the
five patients had received a meningococcal vaccination previously.”
Measles
— United States, 2011: “In 2000, the United States achieved measles
elimination (defined as interruption of year-round endemic measles
transmission). However, importations of measles into the United States continue
to occur, posing risks for measles outbreaks and sustained measles
transmission. During 2011, a total of 222 measles cases (incidence rate: 0.7
per 1 million population) and 17 measles outbreaks (defined as three or more
cases linked in time or place) were reported to CDC, compared with a median of
60 (range: 37–140) cases and four (range: 2–10) outbreaks reported annually
during 2001–2010. Most patients (86%) were unvaccinated or had unknown
vaccination status. The increased numbers of outbreaks and measles importations
into the United States underscore the ongoing risk for measles among
unvaccinated persons and the importance of vaccination against measles.”
Severe
Varicella in an Immunocompromised Child Exposed to an Unvaccinated Sibling with
Varicella — Minnesota, 2011: “On December 13, 2011, the Minnesota
Department of Health was notified of varicella in a girl, aged 3 years,
admitted to a hospital after a 2-day history of fever of 102.7°F (39.3°C) and
an extensive maculopapulovesicular rash (>500 skin lesions) with vesicles in
the mouth and throat. The child received weekly immunosuppressive therapy with
methotrexate (12.5 mg) for juvenile rheumatoid arthritis diagnosed at age 18
months. Neither she nor her younger sibling, aged 21 months, had received a
first dose of varicella vaccine (routinely recommended at age 12–15 months).
Their parents refused vaccination because of personal beliefs.”
Pertussis
Epidemic — Washington, 2012: “Since mid-2011, a substantial rise in
pertussis cases has been reported in the state of Washington. In response to
this increase, the Washington State Secretary of Health declared a pertussis
epidemic on April 3, 2012. By June 16, the reported number of cases in
Washington in 2012 had reached 2,520 (37.5 cases per 100,000 residents), a
1,300% increase compared with the same period in 2011 and the highest number of
cases reported in any year since 1942.”
Vaccination
Coverage Among Children in Kindergarten — United States, 2011–12 School Year: “In 2011, CDC
reported 17 outbreaks of measles and 222 measles cases, most of which were imported
cases in unvaccinated persons. This was the highest number of measles cases in
any year in the United States since 1996 and highlights the importance of
monitoring measles vaccination coverage at the local level.”
Mumps
Outbreak on a University Campus — California, 2011: “On September
29, 2011, the California Department of Public Health confirmed three cases of
mumps among students recently evaluated at their university's student health
services with symptoms suggestive of mumps. An investigation by CDPH, student
health services, and the local health department identified 29 mumps cases. The
presumed source patient was an unvaccinated student with a history of recent
travel to Western Europe, where mumps is circulating. The student had mumps
symptoms >28 days before the onset of symptoms among the patients confirmed
on September 29. Recognizing that at least two generations of transmission had
occurred before public health authorities were alerted, measles, mumps, and
rubella (MMR) vaccine was provided as a control measure. This outbreak
demonstrates the potential value of requiring MMR vaccination (including
documentation of immunization or other evidence of immunity) before college enrollment,
heightened clinical awareness, and timely reporting of suspected mumps patients
to public health authorities.”
Two
Measles Outbreaks After Importation — Utah, March–June 2011: “Outbreak 1. On
April 5, 2011, a health-care provider notified the Salt Lake Valley Health
Department (SLVHD) of an unvaccinated Salt Lake County resident aged 16 years
with generalized rash (onset April 4) and a 3-day history of sore throat and
fever (101.7°F [38.7°C]). On April 8, a health-care provider notified SLVHD
that an unvaccinated Salt Lake County patient aged 15 years had sought care in
late March with generalized rash (onset March 21), fever (103.7°F [39.8°C]),
cough, coryza, and conjunctivitis. This patient had attended a school class on
March 21 with the patient reported previously. Five additional Salt Lake County
residents were confirmed to have measles, with the last rash onset on April 17,
2011. Outbreak 2. On May 24, 2011, a Cache County resident notified the Bear
River Health Department that her unvaccinated child aged 7 years had signs and
symptoms compatible with measles, including generalized rash (onset May 23) and
fever (101.5°F [38.6°C]). Two unvaccinated siblings of the patient, for whom
the parents declined postexposure vaccination, were home-quarantined and
developed measles, with rash onsets June 1 and 2, respectively. Additionally,
two Cache County residents and one Millard County resident, all family members
of the two siblings, were identified as having measles; the last reported rash
onset was June 16, 2011. In the two outbreaks, separated by 36 days, 13 persons
were confirmed to have measles; nine (69%) were unvaccinated and had personal
belief exemptions.”
Three
Cases of Congenital Rubella Syndrome in the Postelimination Era — Maryland,
Alabama, and Illinois, 2012: “Infant A. In February 2012, an infant
born in Maryland at 36 weeks' gestation and weighing 4.2 lbs (1,910 g) was
noted at birth to have congenital heart defects, hyperpigmented skin lesions,
cataracts, cerebral edema, and pericardial effusion. Hearing impairment was
suspected after the infant failed a hearing screening test before hospital discharge
in February, and bilateral profound hearing impairment was diagnosed by an
audiologist in June. The mother, in her late 20s, was from urban Tanzania. She
reported having a rash around the time of her first missed menstrual period in
June 2011 while in Tanzania. At the time, she did not know that she was likely
a few weeks pregnant. She reported having received all of her childhood
vaccinations in Tanzania, but rubella-containing vaccine had not been part of
the routine vaccination schedule. Infant B. In March 2012, an infant was born
in Alabama by cesarean delivery at 33 weeks' gestational age. At birth, the
infant had generalized hemorrhagic purpura (a blueberry muffin rash) over the
entire body, patent ductus arteriosus, cardiomegaly, thrombocytopenia,
pneumonitis, anemia, and liver dysfunction. Approximately 1 month later, the
infant was transferred to a pediatric hospital, where the infant died in April
2012. The mother was a woman in her late 20s from Nigeria. Receipt of a
rubella-containing vaccine, which is not part of the routine vaccination
schedule in Nigeria, was not recorded at any time. Infant C. In September 2012,
an infant was born in Illinois by cesarean delivery at approximately 32.5
weeks' gestational age, weighing 1.4 lbs (650 g). Conditions noted after birth
included cataracts, Dandy-Walker syndrome (discovered on antenatal ultrasound),
intrauterine growth retardation, thrombocytopenia, chorioretinitis, coarctation
of the aorta (which was repaired), mild liver dysfunction, mildly elevated
transaminases, mild direct hyperbilirubinemia, and persistent elevation of C
reactive protein. The child was discharged in February 2013. The mother was an
immigrant from Sudan in her late 20s. Her rubella vaccination status was
unknown; however, rubella vaccine is not part of the routine vaccination
schedule in Sudan.”
Varicella
Death of an Unvaccinated, Previously Healthy Adolescent — Ohio, 2009: “In April 2012,
as part of the routine review of vital statistics records, the Ohio Department
of Health identified a 2009 death with the International Classification of
Diseases, 10th Revision code for varicella as the underlying cause. Because
varicella deaths are nationally reportable, the Ohio Department of Health
conducted an investigation to validate that the coding was accurate.
Investigators learned that, on March 12, 2009, the adolescent girl was admitted
to a hospital with a 3-day history of a rash consistent with varicella and a 1-day
history of fever and shortness of breath. The patient was started on
intravenous acyclovir (on day 4 of illness) and broad-spectrum antibiotics and
antifungals, but she died 3 weeks later. The case underscores the importance of
varicella vaccination, including catch-up vaccination of older children and
adolescents, to prevent varicella and its serious complications.”
Measles
— United States, January 1–August 24, 2013: “To update measles data, CDC
evaluated cases reported by 16 states during January 1–August 24, 2013. A total
of 159 cases of measles were reported during this period. Most cases were in
persons who were unvaccinated (131 [82%]) or had unknown vaccination status (15
[9%]). Forty-two importations were reported, and 21(50%) were importations from
the World Health Organization (WHO) European Region. Eight outbreaks accounted
for 77% of the cases reported in 2013, including the largest outbreak reported
in the United States since 1996 (58 cases). These outbreaks demonstrate that
unvaccinated persons place themselves and their communities at risk for measles
and that high vaccination coverage is important to prevent the spread of
measles after importation.”
Notes
from the Field: Measles Outbreak Among Members of a Religious Community —
Brooklyn, New York, March–June 2013: “On March 13, 2013, an intentionally
unvaccinated adolescent aged 17 years returned to New York City from London,
United Kingdom, while infectious with measles. This importation led to the
largest outbreak of measles in the United States since 1996. A total of 58
cases were identified, including six generations of measles infection in two
neighborhoods of the borough of Brooklyn. All cases were in members of the
orthodox Jewish community. No case was identified in a person who had
documented measles vaccination at the time of exposure; 12 (21%) of the cases
were in infants too young (aged <12 and="" br="" for="" immunization="" measles="" months="" mumps="" routine="" rubella="" style="mso-special-character: line-break;" vaccine.="" with="">
Notes
from the Field: Measles Outbreak Associated with a Traveler Returning from
India — North Carolina, April–May 2013: “On April 14, 2013, public health
officials in North Carolina were notified of suspected measles infections in
two unvaccinated members of a family. Measles was confirmed by laboratory
testing at the State Laboratory of Public Health on April 16, 2013.
Investigators learned that a third unvaccinated member of the household had
developed fever and rash 11 days earlier, after returning to the United States
from a 3-month visit to India, but measles had not been suspected until
household contacts sought evaluation for similar symptoms. During April and
May, direct and indirect transmission from the returning traveler resulted in
22 identified cases of measles (including the two cases first reported), for a
total of 23 cases overall. Most cases were among residents of a largely
unvaccinated religious community in rural North Carolina. Eighteen (78%) of the
23 patients were unvaccinated, three (13%) had been fully vaccinated with 2
doses of measles vaccine, and two (9%) had unknown vaccination status.”
Measles
Outbreak Associated with Adopted Children from China — Missouri, Minnesota, and
Washington, July 2013: “A boy and a girl, both aged 2 years and with
cerebral palsy, were in the process of being adopted by families in the United
States, but became ill in China before traveling to the United States. The boy
(child A) developed rhinorrhea and cough on June 24. At the time of his
immigration medical examination by a panel physician on June 29, the boy was
found to have a rash on his neck. Because he was afebrile and had no other
symptoms or signs, the rash was diagnosed as contact dermatitis. By the next
day, the rash began on his head and spread to his trunk and extremities, and he
developed a fever. The girl (child B) was noted to be febrile on June 29 during
her immigration medical examination, but no other symptoms or signs were
present. Two days later, the panel physician was told by her adoptive parents
that the girl was afebrile and doing well. However, investigators later learned
that on June 29 the girl had developed cough, fever, and conjunctivitis, and on
July 1 she had developed a rash on her face and neck. On July 4, both ill
children traveled on different flights to the United States. They were
hospitalized shortly after arrival in Washington and Missouri, respectively.
Measles was confirmed in both children by positive immunoglobulin M (IgM)
serology and polymerase chain reaction (PCR), and both were placed on isolation
precautions. Neither child had documented measles vaccination, and their
adoptive parents had executed affidavits, consistent with current policy, for
exemption from the vaccine requirements for immigration until after their
arrival in the United States.”
Notes
from the Field: Measles — California, January 1–April 18, 2014: “During January
1–April 18, 2014, the California Department of Public Health received reports of
58 confirmed measles cases, the highest number reported for that period since
1995. Patients ranged in age from 5 months to 60 years. Most of the 58 patients
were either unvaccinated (25 [43%]) or had no vaccination documentation
available (18 [31%]). Of the 25 patients who were known to be unvaccinated, 19
(76%) had philosophical objections to vaccination, three (12%) were too young
(aged ≤12 months) for routine vaccination, and three (12%) were unvaccinated
for unknown reasons.”
Measles
— United States, January 1–May 23, 2014: “Although measles elimination (i.e.,
interruption of year-round endemic transmission) was declared in the United
States in 2000, importations of measles cases from endemic areas of the world
continue to occur, leading to secondary measles cases and outbreaks in the
United States, primarily among unvaccinated persons. To update national measles
data in the United States, CDC evaluated cases reported by states from January
1 through May 23, 2014. A total of 288 confirmed measles cases have been
reported to CDC, surpassing the highest reported yearly total of measles cases
since elimination. Most of the 288 measles cases reported this year have been
in persons who were unvaccinated (200 [69%]) or who had an unknown vaccination
status (58 [20%]); 30 (10%) were in persons who were vaccinated. Among the 195
U.S. residents who had measles and were unvaccinated, 165 (85%) declined
vaccination because of religious, philosophical, or personal objections, 11
(6%) were missed opportunities for vaccination, and 10 (5%) were too young to
receive vaccination. Measles elimination has been maintained in the United
States since elimination was declared almost 15 years ago. However, approximately
20 million cases of measles occur each year globally, and importations into the
United States continue to pose a risk for measles cases and outbreaks among
unvaccinated persons.”
Notes
from the Field: Outbreak of Pertussis in a School and Religious Community
Averse to Health Care and Vaccinations — Columbia County, Florida, 2013: “On August 30,
2013, the Florida Department of Health in Columbia County was notified of a
Bordetella pertussis laboratory-positive unimmunized child attending a local
charter school (316 students from pre-K through 8th grade) in a large religious
community averse to health care and vaccinations. Kindergarten immunization
records showed that only five (15%) of 34 students were fully immunized with
pertussis-antigen–containing vaccines. In seventh grade, only one (5%) of 22
students was fully immunized with pertussis-antigen–containing vaccines. Of the
children who were not fully immunized in these two grades, 84% had religious
exemptions.”
Measles
Outbreak in an Unvaccinated Family and a Possibly Associated International
Traveler — Orange County, Florida, December 2012–January 2013: “The Florida
Department of Health in Orange County was notified by a child care facility on
January 11, 2013, that a parent had reported that an attendee and three
siblings were ill with measles. All four siblings were unvaccinated for measles
and had no travel history outside of Orange County during the periods when they
likely had been exposed. A fifth, possibly associated case was later reported
in a Brazilian citizen who had become ill while vacationing in Florida. An
Orange County unvaccinated resident aged 10 years developed a fever (maximum
temperature 104.5°F [40.3°C]) on December 25, 2012. Rash onset was on December
28. Additional symptoms included cough, coryza, and conjunctivitis. The patient
was evaluated at a local pediatric urgent care clinic on December 29 and given
a presumptive diagnosis of viral rash of unknown etiology. Patient 2 (aged 7
years), patient 3 (aged 13 years), and patient 4 (aged 4 years) are all
siblings of patient 1, and their illnesses were secondary cases in this
outbreak. All four children in the family were unvaccinated; the parents had
claimed a religious exemption to vaccination. On January 25, 2013, the Florida
Department of Health in Miami-Dade County was notified by CDC of a report from
Brazil of a confirmed measles case in a Brazilian citizen who had visited
Florida during his exposure and infectious periods. Patient 5, aged 20 years,
sought medical care for same-day onset of rash and a 4-day history of fever,
oral lesions, and conjunctival hyperemia at a Miami urgent care facility on
December 30, 2012. Public health officials in Brazil reported to CDC that this
patient had no documented history of measles vaccination and had also visited
Orlando-area theme parks in Orange County during the December 14–21 timeframe; the
theme parks were not identified. The genomic sequence from the patient in
Brazil was identical to the sequences obtained from patients 2–4 in the United
States, suggesting an epidemiologic linkage between these cases.”
Notes
from the Field: Measles in a Micronesian Community — King County, Washington,
2014:
“The United States achieved measles elimination (interruption of continuous
transmission lasting ≥12 months) in 2000. Despite elimination, 592 measles
cases were reported in the United States during January 1‒August 22, 2014, the
highest number since 1994, primarily among unvaccinated travelers and their
unvaccinated contacts. Measles remains endemic outside the Western Hemisphere,
with outbreaks affecting communities in the Philippines, Vietnam, and China. An
ongoing measles outbreak with approximately 350 measles cases and one death in
the Federated States of Micronesia during January–July 2014 also has been
reported. On May 30, 2014, a child in King County, Washington, aged 4 years and
unvaccinated against measles, developed a measles rash 4 days after returning
home from 2 weeks in the Federated States of Micronesia. During the following 5
weeks, 14 additional measles cases (nine laboratory-confirmed B3 wild-type and
five epidemiologically linked) were reported in King and Pierce counties.
Patients were aged 5 months‒48 years (median = 3 years). Two patients were too
young to have been vaccinated against measles according to U.S. recommendations,
nine were aged >12 months and unvaccinated against measles, three had
received 1 dose of measles-containing vaccine, and one had received 2 doses.
Twelve cases occurred in the local Micronesian community, in which many
children and adults have no documentation of measles vaccination; during two
community vaccination clinics early in the outbreak, 71% of the 267 community
members who came to the clinic had no electronic or written vaccination record
nor knowledge of previous measles vaccination.”
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