Measles outbreak 2019: How states make it easy to avoid vaccines


On Friday, more than 270 people across the country, mostly young children, have been infected with the extremely contagious and sometimes deadly measles pathogen since the beginning of the outbreaks since last fall.

In New York, the virus has been spreading since September among orthodox Jews, some of whom reject vaccines on behalf of their children for reasons of unfounded security. In Washington, mistrust of health officials and pharmaceutical companies appears to be pushing parents to withdraw, leading to 53 cases since January 1. (Nearly one in four kindergarten children is not vaccinated at the epicenter of the outbreak, Clark County.) There are also cases. Texas, Oregon, and western and southern New York State.

These outbreaks will cost the states and the federal government millions of dollars. They will turn away from other important public health programs. More importantly, they will put at risk those who can not be immunized – people allergic to vaccines, newborns -.

But here is the most frustrating part: all of this is totally avoidable. In 2000, thanks to the measles vaccine, the virus was eliminated in the United States. It is absurd that epidemics have re-emerged, but there is a unique reason: too many states make it too easy for parents to avoid vaccines on behalf of their children.

In other words, measles is making a comeback because of a policy failure.

At present, most people with measles have not been immunized against the virus. They all live in places that allow for various non-medical exemptions from drugs – religious or philosophical.

But some states, like Mississippi and West Virginia, do not tolerate these loopholes; their vaccination coverage rates are higher and they have not had to cope with a recent outbreak. Researchers have repeatedly shown that when parents avoid vaccines more easily, they benefit – and vaccine exemptions increase. So if we want to prevent dangerous, costly and useless measles outbreaks – like the half dozen that are happening right across the country – we have to fill the gaps in immunization. And, as California's recent experience has shown, it will probably take more than the ban on religious and philosophical exemptions for vaccines.

When measles immunization coverage falls below 95%, "epidemics are inevitable"

Before going into insignificant details of state immunization policies, we must understand why measles immunization is so essential.

It is no exaggeration to say that measles is one of the most infectious diseases known to man. When people are not vaccinated, it is extremely easy to get measles. In an unvaccinated population, a person with measles can infect 12 to 18 others. This is much higher than other viruses like Ebola, HIV or SARS. (With Ebola, one case usually leads to another 2. With HIV and SARS, one case usually leads to four others.)

In the United States, before the introduction of a vaccine in 1963, there were 4 million cases of measles, with 48,000 hospitalizations and 500 deaths in the United States each year. Measles was also one of the leading causes of death in children.

Nowadays, with two doses, the measles vaccine is 97% effective in individuals. But for the vaccine to protect the population, including the small number of people who can not be vaccinated, we need what is called collective immunity. Depending on the virus that a vaccine prevents, one must vaccinate a certain percentage of people to prevent the disease from spreading among populations (to achieve collective immunity). Measles spreading so easily, the percentage needed for collective immunity is very high.

"As soon as [measles] Seth Berkley, director of Gavi, of the Vaccine Alliance, warned in a recent CNN article that "epidemics are inevitable." This means that almost everyone in a community that can get the vaccine has to be explained to stop the virus from spreading.

The era of lax vaccine policies must come to an end

But state legislators have implemented policies that in many cases prevent parents from evading vaccines.

In fact, it was the measles epidemics of the 1960s that prompted states to require children to be immunized before starting kindergarten. In the 1980s, all states had mandatory vaccination laws. The idea of ​​these laws was simple: almost universal vaccinations maintain the immunity of the flock.

Nevertheless, vaccination requirements vary considerably across the country. Although all 50 states have legislation requiring vaccines for students entering school, almost all states allow exemptions for people with religious beliefs against immunization and 18 states grant exemptions philosophical to those who oppose vaccines because of personal or moral beliefs. (The exceptions are Mississippi, California, and West Virginia, where the country's strictest vaccine laws allow only medical exemptions.)

In these places, withdrawal may mean simply listening to a doctor or health official, explaining the benefits of vaccination or obtaining a signed statement of your notarial religious beliefs. It is often harder for parents to get their children out of school for the day than to help them avoid vaccinations.

In 45 states, even without exception, children can benefit from "conditional entry" to school by promising to be vaccinated, but schools do not always care to follow up.

We have plenty of evidence, spanning more than a decade, that demonstrates that when parents have an easier time getting out of the injection, vaccine exemption rates tend to be higher. high. The latest US vaccination policy review in 2018 found that states allowing religious and philosophical exemptions – as 18 Member States currently do – were associated with a 2.3% decrease in vaccine vaccine rates. measles, mumps and rubella and a 1.5% increase in total exemptions and exemptions. non-medical exemptions.

Each state also authorizes medical exemptions for people likely to be harmed by a vaccine, such as those whose immune system is weakened due to illness or allergy to the vaccine ingredients. And there does not seem to be a shortage of charlatan health professionals who will subscribe to dubious medical exemptions for people not suffering from legitimate health problems.

In addition, only nine states require annual (or more frequent) recertification for medical exemptions. For example, if a child in a kindergarten to grade 12 school receives an exemption in kindergarten, it will follow him to college. He will never be asked to renew this exemption.

So there are many ways for people to get rid of vaccines. "Establishing administrative control over vaccine withdrawal is vitally important," said Diane Peterson, assistant director of immunization projects at the Immunization Action Coalition. "It should not be easier to get out of vaccination than to get vaccinated."

California struggled to give up vaccines – with mixed and informative results

Some states have taken steps to combat vaccine scavengers, including California, and the experience is revealing for states likely to want to remove some of their loopholes.

Former California governor Jerry Brown signed a controversial bill in 2015 that abolished non-medical exemptions, forcing nearly all state students to get vaccinated unless they had a medical reason not to. participate. SB277 was a response to a major measles outbreak in the Disneyland theme park.

According to the state health department, the number of kindergarten students in the 2017-2018 school year with all required vaccinations rose to 95.1%, a 4.7 percentage points higher than in 2014-2015 and the second vaccination rate reported by health authorities.

Some contradictory data is hidden in this increase, said Saad Omer, vaccine researcher at Emory. Since the promulgation of the law, medical exemptions have also increased, suggesting that the crackdown on non-medical exemptions could have an unintended effect.

But something else was going on in California and that was offsetting the increase in medical exemptions. To explain: in parallel with the removal of non-medical exemptions through SB277, California launched the "Conditional Candidate Response Project" in 2015. The idea was that public health professionals work with local health services to identify schools with high rates of conditional admissions. with them to make them fall.

Between 2014 and 2014, Omer and his colleagues found a sharp 23% drop in the conditional admission rate between 2014 and 2015. Thus, even with the increase in medical expense exemptions, the overall exemption rate for vaccines has further declined thanks to the decline in the number of conditional vaccine entries. to schools.

Omer told Vox, "I do not neglect the elimination of non-medical exemptions. It is a reasonable option. But that may not solve all the problems. "

Mississippi and West Virginia have shown that strict immunization laws can work – but again, interpret them with caution.

Vaccination rates in Mississippi and West Virginia – the other two US states that do not allow non-medical exemptions – are still among the best in the country. In the 2014-2015 school year, more than 99 percent of Mississippi preschoolers had received their MMR vaccine and diphtheria, tetanus and pertussis vaccine – the highest rate in the US . Rates for these vaccines were 98% for kindergarten children in West Virginia. These figures are well above national averages (85% for diphtheria, tetanus and pertussis and 92% for measles, mumps and rubella).

But these two states also have demographic data that likely contribute to immunization coverage. Researchers have repeatedly found that parents at the top end of the socio-economic ladder, including those who send their children to private or alternative schools, tend not to be vaccinated. Mississippi and West Virginia are among the poorest states in the country.

Perhaps these demographic factors contribute to high vaccination rates in both states, authors of a recent analysis in Health Affairs suggested:

Of the US states, Mississippi and West Virginia rank respectively in the fiftieth and forty-ninth ranks for median income, and forty-ninth and fiftieth respectively for the percentage of people aged 25 and over with a bachelor's degree. Thus, states may have a smaller number of people likely to have anti-vaccination ideas and have the political and social capital to undertake successful efforts to influence their legislators.

This suggests that excluding illegal non-medical exemptions may not be a panacea in states where a high percentage of parents use their social capital to spread their anti-vaccine ideas. And as we saw in California, a ban on non-medical exemptions could even turn against other immunization gaps.

Decision-makers therefore need to find ways to make churn more difficult – by repressing conditional school enrollment, introducing exemptions with regular renewals.

And they should go fast. The percentage of people seeking non-medical exemptions – although still low – also increased from 1.1% in 2009-2010 to 2.2% in 2017-18. Outbreaks in recent years have also grown, Omer said. "It's the canary in the coal mine for me."

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