Our Best Shot

In 2014, the United States saw 668 cases of measles in 23 different outbreaks—the most measles here in nearly a quarter century. One of the largest outbreaks was linked to Disneyland in California, where kids, parents and park workers alike got sick.

And 2015 looks worrisome, too: As of April 17, there had already been 162 measles cases in 18 states. Most of those sickened have been children under age 5. About one quarter of the measles victims required hospitalization.

All this from a disease the CDC declared “eliminated” in the U.S. in 2000, thanks to a safe and effective vaccine developed more than 50 years ago. Measles, of course, remains a dangerous menace in developing countries, where it killed more than 145,000 people last year. And importations to the U.S. are relatively common.

Why the resurgence here of this scourge marked by high fever and rash? Blame declining measles vaccination rates, at least in pockets of the country.

Some parents—propelled by misinformation—have come to fear vaccines more than the diseases they prevent. Analysis has found that in some areas experiencing outbreaks, measles vaccination rates had fallen to as low as 50 percent. Rates of at least 95 percent, if not higher, are required to readily prevent the disease’s spread and provide “herd immunity.”

The CDC maintains a recommended vaccination schedule for children, and all states mandate vaccinations before attending school (though the particulars vary). Children with medical contraindications are granted exemptions in all states, and 48 states also allow exemptions on religious and/or personal beliefs. According to CDC figures, more than 80 percent of those stricken with measles by the midpoint of last year’s epidemic had avoided vaccination by using nonmedical exemptions.

“Maybe the publicity surrounding these Disneyland outbreaks will do some good,” says Diane Griffin, MD, PhD, professor of Molecular Microbiology and Immunology. “We haven’t had much measles and people forget what a bad disease it is—lots of complications, hospitalizations, long-term neurologic deficits. We developed a vaccine for a good reason.”

Paul Offit, MD, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia (CHOP), is more blunt. “I think that the measles outbreak in Disneyland has been a tipping point because now we have parents who are really angry at those parents who are choosing not to vaccinate their children because it puts not only their children at risk, but also those with whom they come in contact,” says Offit, author of Deadly Choices: How the Anti-Vaccine Movement Threatens Us All. “You hear those angry voices in the media now all the time and that didn’t used to be true.”

So what should the public health response be to fewer vaccinations? First, take a step back and a deep breath, counsels Dan Salmon, MPH, PhD.

“I don’t think there is a raging anti-vaccine movement in the U.S. I really don’t,” he says. “There are a small number of very vocal groups. Our problem is there are a lot of parents who have concerns and they may not feel their concerns are being addressed. They are not opposed to vaccines in an ideological way but are worried about what’s in the best interest of their children.”

Salmon and other experts advise taking a reasoned approach to improving vaccination rates. Consider the following six strategies.

1. RATCHET DOWN THE RHETORIC

Salmon takes umbrage with people being indiscriminately described as “anti-vaccine” (or branded an “anti-vaxxer”). “It’s a term that’s overused and divisive. A parent asks questions and often is labeled as ‘anti-vaccine.’ Name-calling is seldom helpful,” says Salmon, who is also deputy director of the School’s Institute for Vaccine Safety, founded in 1997 as a clearinghouse for vaccine information.

The good news is that most parents do fully vaccinate their children and national vaccination rates remain high. The U.S. is certainly in much better shape than Europe, which saw 10,000 measles cases in 2013, with three deaths. (France alone had 14,000 cases and six deaths in 2011.)

With an avalanche of evidence of vaccine safety and effectiveness, it is understandable that some in public health have become frustrated or even angry. Saad Omer, MPH ’03, PhD ’07, an associate professor in Global Health, Epidemiology and Pediatrics at Emory University, seconds the call for cool heads and a calm presence.

“I like to say that if yelling at parents was a good communications strategy, then teenagers would have been the most effective communicators,” says Omer.

Only about 3 percent of parents are “hard core” in their belief that vaccinations are dangerous and/or unnecessary, Omer says. “It’s very hard to change their minds,” he says. Most parents are vaccine supporters, and only 20 to 25 percent are “vaccine sensitive.” They should be the main focus of communications, he says.

2. PUT COUNSELING ON THE CLOCK

The pediatrician’s office could be considered ground zero for communication efforts, but there are roadblocks.

The most strident of those opposed to vaccinations see a moneymaking conspiracy between doctors and pharmaceutical companies. In reality, vaccinations can be a money loser for doctors after you factor in record keeping and inventory requirements for perishable vaccines. And addressing parental concerns takes valuable time.

A recent study showed that in over half the instances when parents raise questions about vaccine safety, nearly 20 minutes are added to the visit. And a recent Pediatrics study found that in today’s time-pressed environment, a majority of pediatricians ultimately give in when parents make requests to alter the vaccine schedule.

“We need to improve the compensation of physicians for the very important responsibility of providing counseling about vaccines,” Salmon says. “From a public health standpoint, one of the things that can be done is to make specific coding for the billing of vaccine counseling.”

3. STUDY ALTERNATIVE PROVIDERS

Institute for Vaccine Safety director Neal Halsey, MD, notes that some parents who forgo vaccines for their children do so under the false belief that following an “alternative” or naturopathic approach to health will protect their children.

“They believe that good diet and good parenting is enough to protect a child,” says Halsey, an International Health professor. Some even suggest that the preferred and “natural” way to attain lifelong immunity to measles is to actually be sickened by it as a child. This approach, at its most extreme, can be seen in the pages of Melanie’s Marvelous Measles, a children’s book whose namesake girl is “proud of her rash” and where the disease is described as “quite benign” and even “beneficial.”

“Yes, measles is natural—as are a lot of things that can kill you,” says CHOP’s Offit. “It’s a miserable disease even if you aren’t hospitalized or killed. Suffering is never good.”

While it is known that parents who choose not to vaccinate their children are more likely to embrace complementary and alternative medicine, it’s not well understood how these providers address vaccination with patients.

Salmon and colleagues would like to survey chiropractors and naturopaths to fill this void. “Once we understand what they think and what they do with their patients, we could then develop interventions and information for them so maybe we can influence them,” Salmon says.

4. ADDRESS FEARS WITH SCIENCE

As long as there have been vaccinations, there has been some fearful public pushback against them. When compulsory smallpox vaccination began in 1850s England, thousands took to the streets in violent protest. (Edward Jenner, dubbed “the father of immunology” for creating the smallpox vaccine, is credited with saving an estimated half a billion lives and paving the way for the global eradication of the disease.)

Today, there is a vocal camp of people who fear vaccinations cause autism or other neurological disorders. These beliefs can be traced to Andrew Wakefield’s totally discredited 1998 Lancet study—involving 12 children—that suggested a link between the MMR (measles, mumps, rubella) vaccine and autism. Wakefield was shown to have fabricated some of the data and failed to reveal egregious conflicts of interest. The paper was withdrawn, and he lost his license to practice medicine. Meanwhile, 14 studies involving millions of children have failed to show a causal link between the MMR vaccine and autism. Still, these and other vaccine fears remain in wide circulation and have been stoked by celebrities like Jenny McCarthy.

Before coming to the Bloomberg School, Salmon was the director of Vaccine Safety for the National Vaccine Program Office, Department of Health and Human Services. He can readily attest to the rigors of the system in place to ensure vaccine safety. Still, he says, science can always do more to address parental fears around vaccine safety.

“A lot of the concerns that parents express are based on things other than scientific issues,” notes Salmon, “but they might still be addressed by science.” For example, many parents are alarmed by the number of vaccines now administered at once (as many as five), or the six vaccines given in the first two months of life. “Because a lot of parents are concerned about this, even if the scientific level of concern is not great, we should really make an effort to study it more,” he says. “We can be more responsive to public concerns.”

5. START EDUCATION EARLY

It may never be too early to begin vaccine education efforts. Salmon, Halsey and other researchers at the School are developing and field-testing a multifaceted intervention program for pregnant women and their children. It’s designed to make positive changes in vaccine acceptance. Among its features: vaccine education training for doctors, along with vaccine talking points to be used with patients.

The program also establishes a designated “vaccine champion” at each obstetrics practice to coordinate vaccine education efforts (putting up posters and the like). Expectant mothers, meanwhile, are provided with an electronic tablet-based program that collects demographic data and vaccine concerns. It then provides information on the topics she is interested in, “in a
way that is educationally and culturally appropriate,” Salmon says.

6. USE THE LAW TO NUDGE, NOT CUDGEL

A direct way to bolster vaccination rates is through the law. With many states seeing an increase in not just measles, but pertussis (whooping cough) and other childhood diseases, some statehouses are making nonmedical exemptions to school immunization requirements more difficult. The National Conference of State Legislatures reports that more than a dozen states have introduced legislation to tighten the rules for such exemptions, or in the case of California, remove personal-belief exemptions altogether.

Salmon was involved with an earlier study at the School that found a clear link between easily granted vaccination exemptions and an increase in pertussis. Now he is leading a new study looking at four states—California, Oregon, Vermont and Washington—that have already added restrictions to their exemption rules.

“We will look at how hard they are to implement and what impact they have on exemption rates and then take a model exemption law that we wrote about a decade ago and revise it based on this information,” he says.

Simply eliminating all nonmedical exemptions might, at first, seem the most effective way to raise vaccination rates, but the School’s Salmon and Halsey and Emory’s Omer don’t recommend it. They consider nonmedical exemptions a purposeful “pressure valve” in an often-overheated political arena. Eliminating exemption laws can spark a bruising political backlash.

“I think the laws that are most effective work as strong nudges; they don’t work as a cudgel,” Omer says. “Perhaps the best way to deal with the issue is to make it harder to obtain exemptions. Not out of spite, but the very reasonable demand that those who want to exempt their kids should go through some additional steps, such as going to a physician or going through an education program.

“The act of vaccinating takes effort and multiple doctors visits,” he continues. “The balance of convenience in some states, however, is highly in favor of getting your child exempted. You can just download a form and check a box. Adding exemption requirements, rather than eliminating them, is a more mature and more strategic approach.”