Synopsis: Measles is more widespread than it has been in years. The current measles outbreak in several states has prompted questions about the responsibility of parents to have their children immunized against vaccine-preventable diseases. Experts discuss this “social contract” cited by courts since colonial times, and why highly-contagious measles is a good test case for the rights and responsibilities of parents.

Host: Reed Pence. Guests: Dr. John Swartzberg, Clinical Professor Emeritus, University of California Berkely School of Public Health; Dr. William Schaffner, Professor of Preventive Medicine and Infectious Disease, Vanderbilt University; Alta Charo, Warren P. Knowles Professor of Law and Bioethics, University of Wisconsin

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Measles and Vaccinations

Reed Pence: If you’re older than about 60 years old, you’ve probably had measles. Catching the measles used to mean a week or 10 days of misery, with a fever, the characteristic rash, cough, eye inflammation, feeling just plain miserable… And often a lot worse.

John Swartzberg: In the early part of the 20th century the United States, in young children, the mortality rates were sometimes approaching ten percent. And in the developing world today in young children the mortality rates also approach ten percent. So this is not just a little rash and fever.

Reed Pence: That’s Dr. John Swartzberg, Clinical Professor Emeritus at the University of California Berkeley School of Public Health.

John Swartzberg: It has a substantial amount of morbidity and mortality, and I want to emphasize the morbidity piece as well, because what I mean by that is that people can get awfully sick, they can get pneumonia they can get encephalitis infection in the brain. And the encephalitis for example can lead to permanent damage for the rest of their lives. So, this just not a run of the mill little cold.

Reed Pence: And it doesn’t spread like a little cold, either. Measles is one of the most contagious viruses around, according to Dr. William Schaffner, Professor Of Preventive Medicine and Infectious Diseases at Vanderbilt University.

William Shaffner: When we exhale, the measles virus comes out in the air that we exhale. Now we all know influenza spreads this way, but the way influenza spreads you have to be within three feet of the person who is exhaling the influenza virus to pick it up. Of course that can happen with measles too, but measles is so infectious, if a person is in a room exhaling the measles virus and then that person leaves the room, and a susceptible person comes in an hour later, and breathes that same air they can become infected. You don’t even have to have person-to-person contact to spread measles it can spread like wildfire.

Reed Pence: That’s especially true because when someone’s infected, they’re contagious before they even know they’re sick.

William Shaffner: This means that a perfectly healthy child who is going to get measles tomorrow, will start with the symptoms tomorrow, already today can be spreading the virus. So the virus can be spread actually for a day or even two before the person actually becomes ill. Another means for rapid spread to the unaware and susceptible.

Reed Pence: Those are among the reasons the current measles outbreak has spread so far, so fast. Far more than 100 people have been afflicted in more than a half dozen states, and at least in California, one of every five sickened has required hospitalization. Schaffner says it’s likely that someone caught measles overseas, then came to the U.S. to vacation at the one place where it could perhaps be spread most quickly–Disneyland.

William Shaffner: This was a perfect storm: you’ve got the spread of measles among all these kids, and some of these children have then gone home to other states, to Canada, to Mexico and have begun to set up satellite outbreaks in their home communities.

Reed Pence: Outbreaks are more likely in those home communities if a fair proportion of parents have withheld their children from vaccination, typically over safety concerns.

John Swartzberg: There are people who are genuinely concerned about having all these immunizations done in very young children, and they see the doctor coming with a needle and injecting something into their child that is going to make their child cry for a disease they’ve never seen before, and that doesn’t really exist much within our society, and they really start to question that. It makes people hesitant.

Reed Pence: It’s a trend that’s increasing, according to Alta Charro, Warren P. Knowles Professor Of Law And Bioethics at the University of Wisconsin.

Alta Charro: In the public health community, there has been a recognition that we are entering a period of outbreaks for a variety of things. Whooping cough, for example, has been a visible problem now for several years, some states having particularly bad outbreaks in areas where the vaccination rates had really gone down quite a bit. So, in the public health community, people knew that we were now seeing clusters of vaccine-hesitant or vaccine-refusing parents.

John Swartzberg: People in public health have been very worried about this for a long time, and have been trying to communicate to the public albeit not terribly successfully that immunization remains a very important public health tool. And frankly because there weren’t very many cases of measles, the public health message was falling on deaf ears. It’s almost ironic the success of the immunizations have lead to a population now that has never seen cases of measles. Most doctors haven’t seen cases of measles. So, no one thinks it’s terribly important and that apathy has in part has lead to too many people being not immunized.

Reed Pence: A survey by the Pew Research Center suggests that’s true. While 90 percent of people over age 50 believe the measles-mumps and rubella vaccine is safe, people of childbearing age are less sure. Only 81 percent of people age 30 to 49 agree. And people age 18 to 29 have an even worse opinion of the vaccine. Sixty-seven percent think it’s safe. So Schaffner says too many parents opt out, avoiding what they feel is the greater risk.

William Shaffner: Measles is unknown as a disease because now the mom didn’t experience measles the mom of the child nor did her mother the grand-mother, so there isn’t this knowledge within families, to at the very least, respect and, even better, fear the disease. And if you don’t respect or fear the disease you don’t value the vaccine, so it’s an unknown. Number two of course is this terrible myth that was perpetrated by a most unfortunate and now completely invalidated and discredited publication about 15 years ago, linking measles vaccine with autism. That’s bogus. It’s phony. There’s no truth to that — that’s been studied from here to Timbuktu and all the studies are re-assuring there’s no such association, but that notion persists.

Reed Pence: Many public health experts such as Swartzberg have run out of patience with anti-vaccine activists. He says their decision not to immunize affects more than just one child.

John Swartzberg: We have a responsibility to ourselves, to our children, and to the community that we live in and each of those are very important responsibilities and have to be taken very seriously. If I didn’t immunize my child, and my child developed measles my child could spread measles to some other child that hadn’t been immunized. And there are some children who can’t be immunized, that is they can’t be immunized because they have cancer and are in chemotherapy, or they are immunocompromised in some other way.

Reed Pence: Also unprotected are those who are too young to be immunized. The m-m-r vaccine can’t be given to those less than six months old, and it’s not recommended until an infant is a year old. Ordinarily, what keeps those kids safe is something called “herd immunity.” but vaccine refusal breaks that apart.

John Swartzberg: If everybody in a school is immunized against measles, and then someone else comes in who hasn’t been immunized that child is not going to get measles in that school because no one else in the school is going to have measles, so the herd has immunity. Because measles is so contagious, the percentage of people that need to be vaccinated to get adequate herd immunity is above 90%, so it means we have to have a very high percentage of the population immunized to make it very unlikely that someone who is not immunized could get infected.

Reed Pence: “Herd immunity” is a good thing. Except, Charro says, when someone tries to ride its coattails unfairly, figuring they can skip immunizing their child and still be safe.

Alta Charro: It is in some ways an effort to be a free rider. This is an effort for a family to say we want the benefit of our child being protected by having all your children vaccinated so they become a kind of circle of protection around my child. But my child is not going to suffer even the momentary discomfort let alone the incredibly remote risk of some adverse event, so my child is a free rider on all of your children’s agreement to undergo vaccination. And that just seems selfish and wrong.

Reed Pence: But is it illegal? Should parents be required to worry about everybody else? Schaffner says immunizations are part of the social contract. The same one that says we all stop at a red light and go on a green. We don’t put up with traffic violations because they endanger everyone else. And Charro  says we historically haven’t put up with vaccine refusal, either.

Alta Charro: We have since the very founding of this country understood that the limits of personal liberty and the limits of parental discretion are going to be formed at the point where that autonomy creates a danger to others. So, we have in fact had vaccine mandates for a very long time in this country. We’ve had vaccination programs going back to colonial days. We have key supreme court decisions about the legitimacy of state rules that say you cannot do certain things like come into a public school, for example, unless vaccinated– the Supreme Court upholding that where the nations public health and the safety of its citizens trumped claims of personal autonomy.

Reed Pence: Today state law usually decides a parent’s legal obligation. Mississippi and West Virginia allow immunization exemptions solely for medical reasons, and as a result, they have the highest immunization rates in the country. Nineteen states waive requirements for personal or philosophical beliefs, and 48 states allow religious exemptions.

Alta Charro: Well there aren’t really many religions that actually prohibit vaccination. So that is a somewhat narrower kind of exemption but it’s problematic because it puts the state in the position of having to decide what is a real religion, and evaluating what is the real doctrine of that religion and evaluating whether this parent is in fact sincerely believing in that doctrine. These are questions the state does not want to have to ask. So for the sake of simplicity, as well as for the sense of fairness there are many other states that have broadened that non-medical exemption to include “philosophical objection.” Now were basically at the point where any parent can say for any reason at all “I don’t like vaccines” and say “I don’t want my child vaccinated, but none the less I want my child to have the full range of rights to enroll in school and to participate in group activities, even though the reason my child is unvaccinated and therefore a potential threat to the community is just because I don’t feel like it.”

Reed Pence: Ironically, Schaffner says, the United States is the only country in the western hemisphere where measles is still transmitted. And it’s likely that before the year is over, thousands of children will be sickened with measles in the U.S. If there’s a silver lining to the current outbreak, it’s that an apparently increasing number of parents have been shaken out of their complacency and brought their kids in for vaccinations. Legislators in some states have also started talking about the chances of beefing up immunization requirements.

Alta Charro: There is now a moment for reconsideration I think of what kind of exemptions we think are appropriate and what kind of measures should be taken even if you’re going to keep the exemptions to make sure that parents find it at least as hard to be exempted as to get vaccinated.

Reed Pence: Charro says people are also starting to talk about the possibility of lawsuits against parents who don’t get their kids vaccinated when a classmate gets seriously ill as a result. Those suits may not succeed, but Charro says the mere mention may signal a turning of public opinion. Perhaps it is unreasonable to forgo vaccinations without very good justification. Perhaps we do have a duty to protect all children. You can find out more about all our guests on our website Radio health journal-dot-net. You can always find our shows on iTunes and Stitcher. I’m Reed Pence.

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