Photo credit: Wavebreak Media
Measles has reared its ugly head again, despite having been declared eradicated in the United States in 2000. Two generations have grown up in a world in which measles was on the decline or virtually non-existent after a vaccine was introduced in 1963. Now, thanks to a vigorous anti-vaccination movement and increased global travel, measles is making a comeback.
In the U.S., 1,250 measles cases were reported according to the Centers for Disease Control (CDC) as of the beginning of October. Outbreaks have occurred in 31 states. Wisconsin is one state that has not yet had a measles outbreak.
The World Health Organization (WHO) reports that the measles vaccine prevented an estimated 21 million deaths from 2000 to 2017. Prior to the development of the measles vaccine in 1963, measles caused 2.6 million deaths worldwide each year. Before the vaccine was actually in use, Wisconsin had more than 68,000 cases of measles and 19 deaths in 1963.
Few Germs Are More Contagious
With measles outbreaks on the rise, physicians and public health officials are concerned. “Measles is incredibly contagious,” says Dr. Marylyn Ranta, associate chief medical officer at Children’s Hospital of Wisconsin. “There are few germs on Earth that are more contagious. That means that if you have somebody who has measles in a room and two hours later somebody who has not been vaccinated steps into that room, he or she has a better than 90% chance of catching measles two hours later.”
Ranta explains that most other germs won’t live that long in public places like stores or airplanes. “Think about how ventilation systems in buildings share air and air handling,” Ranta cautions. “If you have people who are under-vaccinated, meaning they haven't had the full series, or are unvaccinated or are vaccinated but have immune problems, all of those people are at risk.”
In Wisconsin, 2018 Wisconsin Department of Health Services data shows that 50,000 children had medical, religious or personal conviction vaccine waivers for one or more vaccines. Of the 50,000 with waivers, 44,000 had personal conviction waivers. Wisconsin is one of 15 states that has personal conviction waivers. Wisconsin was recently ranked fifth highest in the percentage of students taking vaccine waivers among U.S. states. Health officials and doctors are concerned about the increase in personal conviction waivers that has occurred between 1997 and the present. During the 1997-’98 school year, only 1.2% of students took personal conviction waivers. In the 2018-’19 school year, this percentage grew to 4.8%.
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In 20 years, an anti-vaccination movement has matured. The movement grew out of an article published in The Lancet by Andrew Wakefield, a British physician, who suggested a connection, from a very small sampling, between the measles, mumps and rubella (MMR) vaccine and development of autism in children. Though Wakefield’s “research” was found to be deeply flawed and he had a conflict of interest in funding, MMR vaccine rates continued to drop dramatically after his article was published. To this day, members of the anti-vaccine movement, sometimes called “anti-vaxxers,” continue to cite his work to support their anti-vaccination agenda.
It is no wonder that local health personnel may find it challenging to counter the anti-vaccine websites and social media messaging. Jill LeStarge, communicable disease and immunization program supervisor at the City of Milwaukee Health Department, says the exemption rate is high, in part, due to the increased information from the anti-vaccine groups. “This is a multi-faceted problem that is difficult to address,” LeStarge says.
Social Media Amplifies Anti-Vax Message
Social media has proved to be an effective vehicle for amplifying the anti-vax message. In a paper presented at the American Association of Public Health Convention in 2015, researchers conducted a content analysis of 480 anti-vaccine websites and found that they contained considerable misinformation, including the following: Vaccines were dangerous (65.6%), cause autism (62.2%) and “brain injury” (41.1%). Websites used both selective scientific evidence (64.7%) and anecdotes (30.0%) to support these claims. Anti-vaxxers invoked values such as choice (41.0%), freedom (20.5%) and individuality (17.4%) to underwrite their positions, and they co-promoted behaviors, which included the use of alternative medicine (18.8%) and homeopathy (10.2%), as well as eating a healthy (18.5%) or organic (5.2%) diet. Cleansing one’s body of toxins (7.1%), breastfeeding (5.5%) and religiosity (6.8%) were also promoted.
In addition to hundreds of anti-vax websites, social media was used extensively to amplify the anti-vaccine message. A 2018 study, published in the American Journal of Public Health, found that bots and Russian trolls amplified the anti-vaccine debate between 2014 and 2017. The Russian tweets have now been removed. Using a set of almost 2 million tweets, the study found that whereas bots that spread malware and unsolicited content disseminated anti-vaccine messages, Russian trolls promoted discord by accounts masquerading as legitimate users, creating false equivalency between the anti- and pro-vax proponents, thus eroding public consensus on vaccination.
“I think there’s a problem that we all face in that there’s an abundance of information available and very little in the way of anybody who is a referee for that information, particularly when we're talking about the internet,” says Dr. James Conway, associate director for health sciences at the Global Health Institute, UW-Madison. “There’s always been distrust of science going all the way back to Galileo, and there’s always been questions about vaccines from when Edward Jenner started immunizing for smallpox.”
Conway says we live in an era where people are questioning the validity of everything.
Simultaneously, medicine “is trying to be more of a partner with people rather than the way it used to be that was more patriarchal, when we would kind of tell people what to do,” he says. “We’re encouraging people to go out and look for information and be educated consumers. At the same time, there's an overwhelming amount of information out there and a lot of people are just not well-educated or scientifically literate enough to know which things are real and which things are not real.”
Conway stresses that vaccines are extensively tested, safe and effective.
Pockets of Under-Vaccination in Milwaukee
Although 92% of children in Wisconsin are up-to-date with vaccinations, there are pockets where children are under-vaccinated. “Anytime we have pockets of people who are not protected, we are concerned,” says Stephanie Schauer, immunization program manager for the Wisconsin Department of Health Services.
According to data from the Wisconsin Department of Health Services, in the 2018-’19 school year, 61% of Milwaukee County schools reported that 90% or more of students met the minimum vaccination requirement. The bad news, however, is that 157 schools (36%) reported minimum vaccination rates below 90%, with 12 of those below 70%.
“We know that where there are lower rates of immunization, that’s where outbreaks are likely to happen,” Conway says. “In schools, children are really in close proximity, and we’re encouraging them to play together and share. It’s a perfect scenario for disease transmission, especially for highly contagious diseases, like smallpox back in the era and now with measles.”
In the 2018-’19 school year—the latest for which data is available—the following Milwaukee County schools had a much higher percentage of students taking the personal conviction waiver than the state percentage of 4.8%:
Tamarack Waldorf School, Milwaukee (30%), Badger State Baptist School, Oak Creek (21%), St. John the Evangelist School, Greenfield (20%), Yeshiva Elementary School, Milwaukee (14%), Wauwatosa Montessori School (14%), Downtown Montessori Academy, Milwaukee (12%) and Grace Christian Academy, West Allis (11%). At another 14 schools, 9% of students took personal conviction waivers: Honey Creek Elementary, Highland Community School, Saint Lucas Lutheran School, Howard Avenue Montessori School, Milwaukee Seventh Day Adventist School, Milwaukee College Prep—36th Street, Blessed Sacrament Grade School, College Park Elementary, Atwater Elementary, Victory Christian Academy, Bayside Middle School, Shorewood Intermediate School, Mount Olive Lutheran Grade School and North Shore Montessori School. In total, 54 Milwaukee County schools (12% of the total) reported personal exemption waiver percentages of 6% or greater.
In addition, at the start of the 2018-’19 school year, vaccinations “in process,” “behind schedule” or “no records” pushed the percentage of students meeting minimum vaccination requirements below 70% at the following schools (the number in parentheses is the number of students meeting minimum vaccination requirements):
Carmen Middle School South Campus (28%), Pathways High (41%), Daniel Webster Secondary School (49%), Lee Learning Center (56%), Milwaukee Excellence Charter School (59%), Audubon Middle School (63%) Morse Middle School (63%), Southeastern Education Center (63%), San Rafael The Archangel (64%), Daniels University Prep (67%) and Milwaukee Scholars Charter School (69%).
In 2018-’19, 15 Milwaukee County schools did not submit reports:
Milwaukee County Correctional Facility South, Franklin; Lutheran Special School, Glendale; Lutheran Special School, Wauwatosa; Lutheran Special School, Hales Corners; New School for Youth Empowerment; Texas Bufkin Christian Academy; Believers Institute; University of Islam; A Promise of Hope Academy; Saint Charles Education Center; Calvary’s Christian Academy School of the Arts; Hillel Academy, Whitefish Bay; Plank Road Complex, Wauwatosa; Wauwatosa Virtual Academy; Milwaukee Academy, Wauwatosa; and Kingdom Prep Lutheran High, Wauwatosa. This year, parents had until Tuesday, Oct. 15, to get their children immunized to meet the minimum immunization requirements.
State Rep. Gordon Hintz (D-Oshkosh) introduced legislation in 2016 to end the personal conviction waiver, which accounts for 90% of all vaccine waivers, greatly outnumbering religious and medical waivers. It never got a hearing. After the growing number of recent outbreaks in 2018, he reintroduced it in April 2019. The bipartisan bill was sponsored by Rep. Tyler Vorpagel (R-Plymouth), Rep. Debra Kolste (D-Janesville), Rep. Jonathan Brostoff (D-Milwaukee), Rep. LaKeshia Myers (D-Milwaukee), Rep. Daniel Riemer (D-Milwaukee) and Senator Tim Carpenter (D-Milwaukee).
The bill is stalled in the Committee on Constitution and Ethics, headed by Rep. Chuck Wichgers (R-Muskego). Hintz thinks it unlikely that the bill will get a hearing anytime soon, despite bipartisan support for the legislation and the support of 20 advocacy groups. Wichgers, who is on record as opposing the bill, did not return phone calls from this reporter about it. Hintz says opposition to vaccines tends to come from younger parents who never experienced infectious diseases first-hand in the pre-vaccine era. “I think it’s going to get worse before it gets better,” he says.
“Once measles gets started, it’s hard to shut down,” UW-Madison’s Conway explains. “It has a really long incubation period. You can get exposed to someone with measles and have no idea you were exposed. You might not develop your own symptoms until 10 or 14 days later. Then, you can expose other people.” Conway says once you contract measles, it gets into your respiratory system and then into your bloodstream. If it lands in your brain, you get encephalitis—inflammation of the brain—which causes seizures and damages nerve structures in the brain.
Measles causes pneumonia in one in 20 cases, encephalitis in one in 1,000 cases. The death rate is one or two for every 1,000 cases. Conway says that hearing nerves are particularly vulnerable, and a common side effect of measles is a loss of hearing. “People can have all sorts of permanent neurologic disabilities if they survive it,” Conway says. “When people are trying to talk themselves into it being OK not to vaccinate, they are kidding themselves.” Stephanie Schauer adds, “It’s not that we’re trying to scare parents, but we want them to recognize the risks that you take by leaving your child unvaccinated.”
Public health officials speak about community immunity, in which high levels of immunization serve to protect the entire community even the few who are unvaccinated. “The immunity of the community protects the most vulnerable in that community,” Conway says. “Whether it’s the person on steroids for their transplant or someone who is on an anti-inflammatory for rheumatoid arthritis or a baby who is too young to be immunized. All of those vulnerable populations depend on community immunity to protect them. Vaccination is one of the simplest ways that people can contribute to that effort.”
A 90% vaccination rate is needed for community immunity for most diseases, Conway explains. But for measles in particular, a 95% vaccination rate is needed, “because it is such a hard outbreak to shut down once it gets started, because of its long incubation period and because people can be contagious before they even realize they are sick.”
The CDC estimates that in the 2017-’18 school year, 91.8% of Wisconsin kindergartners got an MMR vaccine, down from 94.2% in 2009-’10. In this study, Wisconsin was in the bottom tier of states in terms of vaccinations.
Global Travel Drives Measles Outbreaks
Increased global travel is another factor driving measles outbreaks. A recent report found that Cook County was a likely location for the next big measles outbreak because of the large number of unvaccinated international travelers arriving at O’Hare International Airport. So far in 2019, nine cases of measles have been reported in Illinois and 44 in Michigan. “We’ve been lucky that measles hasn’t hit either Milwaukee or Dane County,” Conway says. “It’s amazing to me, with as many travelers as we see every summer coming in and out from Illinois, that it hasn't happened.”
Globally, measles outbreaks are becoming more prevalent. Since the start of 2019, Europe has had approximately 90,000 confirmed cases of measles, well outpacing the 88,000 total for all of 2018. Recently, Albania, Greece, the Czech Republic and the United Kingdom lost their measles-free status. Romania, Italy, Philippines, Israel and Ukraine have had large outbreaks. In 2019, the U.S. came close to losing its measles elimination status. “It doesn’t take much for someone to get on a plane and introduce measles,” added Dr. James Conway.
Milwaukeeans and Wisconsinites hardly live in an insular bubble. As a popular tourist destination, Milwaukee has 23 million visitors annually from other areas of the Midwest, the U.S. and around the world. Likewise, tourism brings 112 million visitors to Wisconsin as a whole. The Bureau of Transportation reports that almost 3.5 million passengers arrive at General Mitchell International Airport annually. In addition, U.S. citizens are traveling to foreign countries with growing frequency.
Vaccines Save Lives
“In the late ’90s, the CDC went and added up all of its successes over the previous hundred years, and vaccines came out to be by far the number one public health measure that has saved more lives and prevented more morbidity than anything else we’ve ever done,” Conway says. “Vaccines are responsible for saving more lives and preventing more illness than anything else in public health.”
WHO lists vaccine hesitancy as one of the top 10 threats to global health in 2019 and reports that, despite the existence of a safe and economical measles vaccine, 110,000 people, mostly children, died from measles in 2017.
Though measles is taking the contagious disease spotlight right now, unvaccinated children are also highly susceptible to a host of other preventable infectious diseases including influenza, mumps, pertussis and pneumococcus. “Every kid deserves to be protected from these common things,” Conway says. “Rotavirus causes diarrhea and vomiting in babies, and pneumococcus is the most common cause of ear infections, sinus infections, pneumonia and meningitis.”
“Much of this comes down to equity. Everybody deserves an opportunity to be protected from diseases,” Conway continues. “I know in my heart of hearts, as a pediatrician speaking on behalf of kids, that no kid, if they were given the chance, would ever want to have any of these diseases if they really knew what these diseases were like.”
“I hate to say it,” he adds, “but in some ways, it is selfish for parents to put their political or fundamental beliefs ahead of their own child’s well-being. I feel for them in some way, because I think they are trying to do the right thing for their kid and protect them, but they’re really making an erroneous set of assumptions that leaves their kids vulnerable to diseases that can disable and kill them.”
Especially at a time when it is reasonable to expect that a measles outbreak might soon hit Wisconsin, physicians and health officials are encouraging all parents to get their children’s vaccinations up to date. They emphasize the proven safety and efficacy of the measles vaccine, despite the inaccurate information to the contrary being spread by anti-vax websites and social media.
