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How Your School Could Become the Next Tinderbox for Measles

Hot spots for measles are scattered across the U.S., in areas rich or poor, in red states or blue.

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A child is prepared for vaccination against measles, rubella, mumps, and chickenpox in Berlin. Although German law does not make it compulsory, most parents have their children vaccinated.


The Waldorf School in this city is part of a fast-growing global chain of private schools with a holistic curriculum emphasizing freedom and individuality.

It is also, in the view of public health officials, a tinderbox for illnesses like measles.

Like Waldorf parents in other states, Seattle’s Waldorf parents tend to be well-educated, mostly liberal, and able to afford tuition that tops out at $22,800 a year. Many are also hesitant to vaccinate their children against childhood diseases. This thinking resonates so strongly that when the measles outbreak began at Disneyland late last year, 28 percent of the Seattle school’s students had not been inoculated against it.

In other words, 83 kids at Waldorf were at risk of catching measles. That is the kind of number that, as the Disney outbreak spread to Washington State, put Waldorf on speed-dial at the Seattle and King County Public Health Department.

“What keeps me awake at night?” says Tracy Bennett, who heads Seattle’s Waldorf school. “If we get a case of measles.”

The Disney outbreak laid bare an ugly divisiveness over childhood vaccines. But more than anything, it revealed how widespread tinderboxes like Waldorf have become as the anti-vax movement gained momentum in the 15 years since measles was declared eliminated in the United States. Clusters of like-minded people disinclined to vaccinate their kids are scattered throughout every state that allows vaccine exemptions—whether in the megalopolises of California or in the rural outreaches of North Dakota. These clusters cross all dividing lines: socioeconomic classes, education levels, and political and religious views. A single common thread unites them: reluctance to vaccinate.

What keeps me awake at night? If we get a case of measles.
Tracy Bennett Waldorf School head

The diversity in these tinderboxes is clearly reflected in Washington State, which in 2008 had the highest rate of vaccine exemptions in the country. The Waldorf School is home to one cluster among many. Other pockets of vaccine-resistant parents can be found on rural Vashon Island, a 20-minute ferry ride across Puget Sound from Seattle; in Bellingham, a midsize college town 17 miles south of the Canadian border; and in the small schools with enrollments of 30 students that dot the wheat fields of eastern Washington and the city streets of conservative Spokane, whose politics and geography are more closely aligned with those of Idaho than those of the tree huggers in and around Seattle.

“If you want to know how bad it can be, look at your population of unvaccinated,” says Jeffrey Duchin, the Seattle and King County Public Health Department’s chief health officer.

“Measles seeks out and finds the unvaccinated very, very well. Once an outbreak gets rolling in an unvaccinated community, that’s when you worry about things getting out of control.”

Vaccination exemptions by state, 2013-14
To estimate the number of U.S. kindergarten students who are exempt from receiving one or more vaccines, the CDC analyzes data collected by federally funded immunization programs. The surveys are aggregated at the state level for students enrolled in the 2013-14 school year, with the total state population surveyed ranging from 0.5 to 100 percent. The national unvaccinated rate is 2.5 percent, with state rates ranging from 0.1 percent (Mississippi) to 7.1 percent (Oregon).
Measles, mumps, and rubella (MMR) vaccine coverage less than 90 percent
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VACCINES EXEMPTIONS BY COUNTY, 2013-14
A county-level breakdown of kindergarten vaccine data shows how much exemption rates can vary within a state. These four states help demonstrate the complexity of the exemption debate. Washington has relatively high exemption rates, while North Carolina’s rate is among the lowest in the country. California, the epicenter of the recent measles outbreak, has high unvaccinated rates in its northern counties. All 50 states permit exemptions for medical reasons, since vaccines can be harmful to immunosuppressed children. All but two states, Mississippi and West Virginia, grant religious exemptions, and 20 states allow personal exemptions based on philosophical and moral objections. States that allow all types of exemptions have higher unvaccinated rates.
Color scale is different for each state to show county-by-county differences more effectively.
Measles, mumps, and rubella (MMR) vaccine coverage less than 90 percent
Washington
Washington's counties have some of the highest unvaccinated rates in the country. The state allows for all types of exemptions, but since 2011 has required parents to consult with a doctor before exemptions are granted.
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San Juan County, 13%

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California allows medical and personal exemptions (including philosophical and moral objections). The state legislature is considering making it more difficult to claim the personal exemption.
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Nevada County, 21%

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Nearly half of North Dakota’s 53 counties have an MMR vaccination rate under 90 percent. Medical, religious, philosophical, and moral exemptions are permitted.
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All of North Carolina’s counties have MMR vaccination rates above 90 percent. The state permits only medical and religious exemptions, helping it maintain its high vaccination rate.
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SOURCES: CDC; CALIFORNIA DEPARTMENT OF PUBLIC HEALTH; IOWA BUREAU OF IMMUNIZATION AND TB; NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES; NORTH DAKOTA DEPARTMENT OF HEALTH; WASHINGTON STATE DEPARTMENT OF HEALTH

None of the Waldorf students have contracted measles, although a case of strep throat created a brief scare. If measles were introduced into a school the size of Waldorf, which has nearly 400 students, the consequences could be catastrophic. Children would be quarantined under public health protocols for 21 days, possibly longer. Working parents might find child care for sick kids difficult to secure. The spread of a serious infection could further polarize parents on both sides of the vaccine divide. And, in self-funded private schools like Waldorf, it could jeopardize the financial health of the school itself.

And yet, Bennett resisted telling her parents how to think, or what to do. That would run counter to the school’s philosophy of individual choice. Waldorf schools, she says, do not advocate for or against immunization.

She’s heard from parents who were alarmed to discover that their children attend school with so many unvaccinated kids, and from parents who passionately hold to the belief that childhood vaccines should be a matter of choice.

“My inbox has been full,” she says. “For families that have deeply held beliefs for whatever reason on this issue, it’s not my role to persuade them otherwise.”

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The epicenter of the latest measles outbreak, which as of March 27 had infected 146 people, was Disneyland in Anaheim, California.


The Geography of Measles

One person can spread measles to about 14 people in a typical day, says Paul Offit, an infectious disease specialist at Children’s Hospital of Philadelphia. It takes 10 to 14 days for one case of measles to lead to another.

As of March 27, the Disney outbreak has infected 146 people in seven states, Canada (ten cases), and Mexico (one case). It is the largest single outbreak since the year measles was stamped out, and the largest among four that have so far this year sickened 178 people—a number that Offit says is on track to top last year’s 644 cases—across 17 states.

Last month, epidemiologists who retraced the geographic spread of the Disney cases confirmed early suspicions that places responsibility for the outbreak clearly in the hands of parents who declined to vaccinate their children.

“Substandard vaccination compliance is likely to blame for the 2015 measles outbreak,” scientists at the Massachusetts Institute of Technology and Boston Children’s Hospital wrote in a research letter published in the journal JAMA Pediatrics.

Using modeling based on infection rates, the scientists calculated that the vaccination rates in the populations of those exposed during the outbreak ranged from a high of 86 percent to a low of 50 percent.

Those rates are sharply below the rate of 96 to 99 percent that scientists say is necessary to achieve “herd immunity”—or the level physicians say is necessary to maintain to prevent measles from becoming endemic again.

“Clearly, vaccination rates in many of the communities that have been affected by this outbreak fall below the necessary threshold to sustain herd immunity, thus placing the greater population at risk,” the scientists wrote.

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A vial of measles, mumps, and rubella vaccine sits atop an information sheet at Boston Children’s Hospital in Massachusetts.


The Disney cases also highlight another risk that clusters of unvaccinated children pose. Although the chances unvaccinated children in the United States could catch measles remain low because immunization rates in the U.S. in general remain high, unvaccinated children are still at risk of catching measles brought to the U.S. from overseas.

Measles is one of the leading causes of death among young children globally, says the World Health Organization. In 2013, 145,700 children died, or 400 every day. Measles thrives year-round in tropical climates. The original patient in the Disney outbreak visited the theme park after having been exposed to measles in the Philippines.

Lab tests at the U.S. Centers for Disease Control and Prevention in Atlanta matched the Disney virus type to the type that caused a large outbreak in the Philippines last year, when more than 21,400 were infected and 110 died. The WHO notes that 25 U.S. travelers returning from the Philippines last year became sick with measles; most of them were unvaccinated.

At any airport, you have some risk of being exposed.
Jeffrey Duchin Chief health officer

“We are challenged on an ongoing basis with people who enter the country exposed to measles where it is endemic,” Duchin says. “At any airport, you have some risk of being exposed. It’s a matter of time before one of these cases goes into the unvaccinated community.”

Can It Be Fixed?

So what’s to be done? Dissuading vaccine-wary parents from their views has proved to be a heavy lift.

“Psychologists tell me that when long-held beliefs are challenged head on, even with facts that disprove it, the immediate response is to double down,” says William Schaffner, who chairs the preventive medicine department at Vanderbilt University in Nashville, Tennessee. “Rather than open your mind and say, ‘Oh, really, I was wrong?’ you hunker down and get more intense in your position.”

So far this year, efforts by lawmakers in 19 states to make it more difficult for parents to legally be exempted from vaccinating their children have mostly stalled. Even a less dramatic slate of proposed bills that would have required parents to learn more about the risks and benefits of vaccines did not gain momentum. One such proposal in Minnesota, requiring parents to meet with a doctor before applying for an exemption, fizzled before it came up for a vote.

“The fury this has caused in my own state of Minnesota is unbelievable,” says Diane Peterson, associate director for the Immunization Action Coalition, which tracks legislation in the 50 states.

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A poster in a clinic in Los Angeles warns about the risk of travel-related exposure to measles. Several state legislatures are considering making it more difficult for parents to opt out of vaccinating their children based on personal beliefs.


The exception may be California. On Wednesday, lawmakers there are expected to consider a bill to eliminate vaccine exemption based on personal beliefs. California is one of 20 states that allow personal belief exemptions and 48 that allow religious exemptions. Mississippi and West Virginia do not allow exemptions other than for medical reasons.

In Washington, bills to end exemptions for philosophical reasons did not survive long enough to come up for a vote. Washington State lawmakers began limiting options for vaccine-hesitant parents in 2011 when they passed a law requiring parents to consult with a doctor in order to obtain an exemption. That change—adding an educational step—was debated for three years before it passed. Since then, exemption rates have declined.

Meanwhile, public health doctors in Seattle launched a campaign in 2008 called Vax Northwest to promote vaccine safety, parent by parent. If millennials get their information from friends and social media, Vax Northwest figured, then their peers could be trained to talk about vaccine science with them.

Kathy Hennessy, a mom and former elementary school teacher, counsels parents in Bellingham. “We are taught to show empathy and help people with their questions, but not to get in a big fight,” she says. “A lot of this is about trust. If they don’t trust where the facts are coming from, that’s it, they’re done.”

At the Seattle Waldorf School, the Disney outbreak reframed the issue. Some parents who had been unaware of public health protocols for quarantines got their kids immunized. Others who had merely fallen behind on vaccines updated them. Waldorf’s measles exemption rate inched down, from 28 percent to 23.

Even so, Bennett remains caught in an almost impossible contradiction—staying true to her school’s philosophy while protecting the school and the health of her students. “This is where the intersection between personal choice and the health of the entire community becomes less clear and increasingly challenging,” she says.

There will be more talk in the months ahead.

“This is not the issue I would choose to cut our teeth on to hone communication skills,” she says. “But it is the issue we have in front of us. Is the current reality one we can live with? Why or why not? If not, how do we look to a different path forward?”

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