The Measles Outbreak Coming Near You

The Measles Outbreak Coming Near You

Parents who won’t vaccinate their children are reviving once-dead diseases. Will a vaccine mandate be needed?

By Haider Javed Warraich in the Wall Street Journal

I was working on the hospital infectious-disease service when our team was asked to see a young girl with a mysterious illness that no one had been able to diagnose. She had come to the emergency room with a fever and runny nose and had a rash spreading across her body. She had developed a cough so harsh that “whooping cough” had been added to the long list of possible infirmities. But when the senior doctor on our team, Frank Berkowitz, an expert in pediatric infections—arrived at her room, he knew the diagnosis immediately: She had measles.

Many developing countries continue to suffer from measles, an extremely contagious respiratory disease, but the U.S. in 2000 was declared “measles free” by the Centers for Disease Control and Prevention. The news of a confirmed case set our hospital abuzz, and uniformed CDC officers soon swooped in.

How did the young girl get the disease? Her parents had refused to vaccinate her.

Hers is far from the only case. Measles is making a terrifying comeback in the U.S., with some 600 cases reported this year, more than in any year in the past two decades. There are two reasons: the ease of international travel, and an increasing number of people refusing vaccinations, usually on behalf of their children.

Because parents seeking exemptions tend to be geographically clustered, these communities can become outbreak hotbeds. For example, the exemption rate in Orchard Prairie in Washington state is 24%, five times higher than the state’s median exemption rate and 13 times higher than the national average.

Forty-eight states offer nonmedical waivers for parents to exempt their children from vaccination, and the states where exemptions are the easiest to get are also home to the highest rates of unvaccinated children. States such as Colorado and Oregon, which only require parental signatures for exemptions, have exemption rates close to 6%, among the highest in the country, according to CDC data.

These refusals have directly resulted in an increase in the incidence of almost forgotten diseases like whooping cough and measles. After the introduction of the whooping cough vaccine in the 1940s, cases dwindled to about 1,000 cases annually. Yet the CDC reported nearly 77,000 cases of whooping cough in 2012 and 2013.

These exemptions raise serious ethical concerns. Human beings, at the start and end of their lives, are often unable to make informed decisions. While the elderly designate others as proxies, children rely on their parents. But when parents don’t allow their children to get vaccinated, they are willfully putting their child at risk of catching easily preventable—and sometimes deadly—diseases.

Refusing vaccinations also puts other children at risk. Vaccines work when given to individuals, but they are most effective when administered to an entire population. That’s because vaccines confer “herd immunity” that disrupts the chain of infections, but only if enough people get the immunization. For a highly infectious disease like measles, that threshold is about 92% of the population. At less than 92%, outbreaks can start to pop up, as is happening now.

Some people—such as chemotherapy patients—cannot be vaccinated. Parents who refuse to vaccinate their children are conferred protection from other children who get the vaccine and maintain a prepared herd—but when refusals reach a tipping point, they put everyone at risk, especially the most vulnerable.

We don’t let people do most things, such as drunken driving, that endanger themselves or others. So why do we allow people to prevent their children from receiving the most effective public-health intervention known to our species?

West Virginia and Mississippi have the strongest position against vaccine exemptions: Neither allows religious or personal exemptions, and neither has had an outbreak in more than 20 years.

When I asked Dr. Walter Orenstein, the former director of the CDC’s National Immunization Program, whether exemptions should be allowed, he offered caution. “I have some concern about ‘forcing’ vaccinations and not allowing any exemptions,” he said. “It could backfire and enhance antivaccination sentiment.” Yet with vaccine exemptions sharply increasing, doctors and public-health experts are running out of options.

Claims about the dangers of vaccines—such as their purported relationship with autism—have been rigorously studied and debunked. Yet anti-vaccine advocates are becoming more vocal. When scientific proof is overwhelming, and reason fails, they fall back on magical thinking. Lindey Magee, an antivaccine advocate in Mississippi, told Newsweek earlier this year, “I saw the Disney movie ‘Bears,’ and if God gave bears instincts to survive their harsh reality, then human beings certainly have the instincts to protect children.” She added, “Mumps, measles and rubella do not scare me.”

By wiping out many common and deadly diseases, and thus the fear they induce, vaccination can be its own worst enemy. However, we cannot afford to remain reactive. Seminal work in 2012 by Saad B. Omer, an epidemiologist at Emory University, has demonstrated that making it more difficult to obtain exemptions—say, by requiring physician consultation, education or annual renewals—reduces the rate of exemptions. “The balance of convenience should tip in the favor of vaccinations as opposed to vaccine exemptions,” he told me.

Physicians are reimbursed for giving vaccines, but there is no incentive to provide counseling for hesitant parents. “I strongly support a billing code that would allow time for vaccine counseling,” Dr. Orenstein added.

The re-emergence of measles may be the harbinger of other infections such as polio returning from the history books. While autonomy needs to be a central value driving medical decision-making, legislators need to protect American children. The young girl at my hospital with measles survived, but others might not be so lucky.

Dr. Warraich is a physician at the Beth Israel Deaconess Medical Center in Boston and an instructor at Harvard Medical School. Dr. Gohar Javed, a research associate at the Aga Khan University in Karachi, Pakistan, contributed to this op-ed.