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America’s Vaccine Dilemma

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.

Consider that in 2000, the Centers for Disease Control and Prevention (CDC) declared the disease “eliminated” in the U.S., thanks to a safe and effective vaccine developed more than 50 years ago. Before that, more than 500,000 cases and 500 deaths were reported each year.

Why the resurgence of the disease? 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.”

All states mandate vaccinations before attending school, though 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 2014’s epidemic had avoided vaccination by using non-medical exemptions.

“Maybe the publicity surrounding these Disneyland outbreaks will do some good,” says Diane Griffin, MD, PhD, professor in the W. Harry Feinstone Department of Molecular Microbiology and Immunology and a presenter at the School's February 9, 2015 symposium—Measles Rises Again: The Science and Policy of a Preventable Outbreak. “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,” Griffin says. 

For decades, the Bloomberg School has taken the lead on the issue of vaccination. In partnership with the World Health Organization, the school established the Collaborating Center for Vaccine Epidemiology and Evaluation. Additionally the Johns Hopkins Vaccine Initiative promotes and encourages current research programs, while identifying new opportunities in vaccine research and policy development.

Part of that includes developing ways to improve vaccination rates. Among their recommendations:

Cool the rhetoric.

Daniel Salmon, PhD, MPH, warns us not to get into unproductive name calling. “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.

Encourage physicians to counsel patients on vaccinations.

Vaccination critics 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—billable time.

“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.”

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.

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.

Address fears with science.

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.

“A lot of the concerns that parents express are based on things other than scientific issues, but they might still be addressed by science.”

Dan Salmon, MPH, PhD, Deputy Director of the JHSPH Institute for 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.”

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.

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.

Use the law to nudge.

With many states seeing an increase in not just measles, but other childhood diseases, some statehouses are making non-medical exemptions to school immunization requirements more difficult.

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.

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

As the vaccination debate rhetoric increases, so too do the number of cases of preventable diseases in the U.S. and abroad. The Bloomberg School has been a prevailing voice of reason in the discussion, appealing to those on both sides of the issue. The next decade will determine whether or not they’re ready to listen.