Measles re-emerges

With an estimated 20 million cases of measles worldwide each year and fewer than 90% of children immunized with the measles-mumps-rubella (MMR) vaccine in some states, a 2013 report from the U.S. Centers for Disease Control & Prevention (CDC) presciently concluded that measles cases imported from other countries “can result in large outbreaks, particularly if introduced into areas with pockets of unvaccinated persons…. Maintaining high MMR vaccination coverage is essential to prevent measles outbreaks and sustain measles elimination in the United States.”

As of mid-February, the CDC’s National Center for Immunization and Respiratory Diseases reported that there had been 141 cases of measles in 17 states and the District of Columbia since the start of 2015. Eighty percent of those were considered to be part of the outbreak that began at Disneyland in Southern California.

That figure puts the U.S. on track to surpass the 644 cases in 27 states from 2014, itself a record number since the elimination of endemic measles here in 2000. Though the current outbreak’s final course remains to be seen, the country seems to have perhaps snatched defeat from the jaws of victory over measles.

Regaining lost ground

The current measles outbreak raises the issue of what can be done, by government or by the healthcare community, to boost vaccination rates.

Historically, the most effective approach has been to mandate vaccinations for school enrollment, notes Stephen L. Foster, Pharm.D., of the University of Tennessee Health Science Center. The percentage of parents who are hesitant about vaccines is going up, however, and parental fears are “an increasing part of the public health program,” so vaccination efforts likewise need to increase. says Claire Hannan, MPH, executive director of the Association of Immunization Managers. Hannan adds that such efforts should target the “hesitant” parents, because hardcore anti-vaccination opponents probably can’t be reached.

NEXT: A role for everyone

Although making it more burdensome to get a vaccine exemption would help, says Alison Buttenheim, Ph.D., MBA, of the University of Pennsylvania School of Nursing, “We have made it pretty easy to opt out of vaccines.” She adds that, until this year, California in particular had a very easy exemption process. Hannan highlights recent laws in Washington, Oregon and California that stiffened exemption requirements by mandating parent education/counseling and annual reauthorization of exemptions, though she notes that similar legislation in Colorado and Vermont failed.

Laws like the new one in California, which went into effect in January 2014 for the current school year, help a lot, says Buttenheim. “We know that tougher exemption regimes mean lower exemptions.”

In the healthcare community, “There’s a role for everyone who touches a patient” to help boost vaccination rates, says George Benjamin, M.D., executive director of the American Public Health Association. Insurers, he says, should be including vaccination

in their health promotion efforts, through partnerships with physicians. And though insurers do currently hold physicians accountable for vaccinations as part of quality assurance oversight, this could be more robust, perhaps through an expanded role for electronic health records (EHRs), he notes.

Healthcare plans should be vigilant about maintaining vaccine coverage rates for all their participants -- and especially for infants, says Hannan, partly because providers often tend to assume that vaccinations are being done on schedule and don’t necessarily verify that information. Furthermore, she adds, health insurers should be sure to cover all vaccinations, follow up with providers, check for any obstacles to vaccination (including financial ones) and make sure to provide vaccination information to state health departments.

Related:Catch up on vaccinations

And though there is some evidence regarding the most effective vaccination messages by providers--such as pointing out that their own kids are vaccinated, says Buttenheim--providers could use better tools to help with this.

At Kaiser Permanente, heavy use of EHRs lets providers carry out what is called the Proactive Office Encounter, which helps identify any care gaps such as overdue mammograms or missing vaccinations, says Robert J. Riewerts, MD, regional chief of pediatrics for Southern California Permanente Medical Group. For example, if a child is brought in for a visit following a fall, even before he or she sees a physician, a nurse will check the child’s vaccination status. And if the child is missing a shot or two, the parent will be offered the opportunity to get the child vaccinated as part of that visit.

Riewerts calls that philosophy “Do today’s work today” and says research shows that good vaccination rates depend on providers being proactive, rather than waiting for patients to take initiative.

Right now, being proactive regarding vaccine coverage is crucial for healthcare insurers and providers. “Herd immunity is obviously a public good, a national asset that has required a ton of investment over the years,” Buttenheim says. “Measles is a very contagious disease. It’s kind of a canary in the coal mine as to our herd immunity.”

NEXT: Vaccination rate in decline

Vaccination rate in decline

When the measles vaccine was first developed in about 1963, there were between 3 million and 4 million cases annually in the U.S. and about 400 to 500 deaths, from the disease, says Foster. By 1966, efforts were underway to eliminate indigenous measles transmission, through high vaccination coverage among children, surveillance of cases and aggressive outbreak control. Although there were setbacks, including a serious resurgence in 1989 to 1991, a final effort brought the reported annual measles incidence below one per 1 million by 1997.

And over the 20 years since then, the U.S. has been largely successful in keeping vaccination rates up, says Benjamin.

Historically, he notes, public health agencies have audited primary-care practices to identify missed vaccination opportunities and held back-to-school clinics that, among other things, checked on vaccinations.

“There have been a lot of things done to raise the U.S. vaccination rates,” Benjamin says. “We’ve made a national effort.” But along the way, success started to slip.

About 94% of the population needs to be immunized to prevent spread of measles, says Paul Offit, M.D., chief of the Division of Infectious Diseases and director of the Vaccine Education Center at Children’s Hospital of Philadelphia, Pennsylvania.

In 2013 the national coverage for the MMR vaccine among children aged 19-35 months stood at 91.9%, according to the CDC, while state-level rates ranged from 95% to less than 90%. These seemingly slight declines in the measles vaccination rate are the main cause of the current outbreak, says Foster.

 “That’s sort of the lesson we’re learning,” that is, that vaccination rates need to be solid and that susceptible pockets disproportionately raise the risk of an outbreak, adds Hannan. Some schools in California, notes Buttenheim, have an only 80% MMR vaccination rate.

So, if inadequate vaccination coverage is the main cause of the current outbreak, what caused vaccination rates to drop?

“Part of it is our success” in curbing so many vaccine-preventable diseases, says Foster. When parents don’t see the diseases, they underestimate them, he says, and it then becomes easier to focus on fears about vaccines.

Benjamin, who was born in the 1950s, agrees that one factor is low fear of measles. “When I was growing up, parents were scared to death of measles,” he notes.

While vaccination is a victim of its own success, he adds that both anti-science and anti-government sentiments also have harmed vaccination efforts.

In fact, vaccination efforts have been plagued not just by passive neglect, but by active resistance in the form of a largely amorphous anti-vaccination movement. And worse, from an epidemiological standpoint, as Buttenheim points out, anti-vaxxers have tended to cluster in certain places, one of which is Disneyland’s home state, California.

According to figures from the Los Angeles Times, Buttenheim says, 2.7% of students in California have vaccine exemptions this school year, versus 3.2% the previous school year. If that small percentage was evenly spread, it would be fine, she explains, but when it’s clustered geographically, it becomes dangerous.

Fortunately, the anti-vaccination movement is not monolithic, and some vaccine-exemption figures might look worse than they really are. Although a few California schools have as high as 40% vaccine exemptions among their students, Buttenheim emphasizes that not all of these children are necessarily unvaccinated. She notes that, for example, parents have been known to claim an exemption when they simply couldn’t find a child’s vaccination records, so many “exempt” children actually are at least partially vaccinated.

Buttenheim’s research on this is currently under way, but she estimates that in California about 60% of “exempted” kids have had one MMR shot and 30% to 40% have received both.

NEXT: Changing minds

Changing minds

Many parents who don’t vaccinate their children “become very comfortable with that decision,” comments Riewerts.

Buttenheim, who believes that the current outbreak is starting to generate serious anti-vaxxer backlash, asks: “How do we change social norms around vaccination?”

One key problem, Offit warns, is that “Evidence won’t change people’s minds.” In debates about any purported autism-vaccine link, for example, he explains, “You’re not asking how many angels can dance on the head of a pin. It’s an answerable question,” and one that’s already been answered, he says, by numerous studies and meta-analyses, including an article in the February 15, 2009, issue of the Journal of Clinical Infectious Diseases. Co-authored by Offit, it reviewed 20 epidemiologic studies and concluded that neither the MMR vaccine or thimerosal (a mercury-containing preservative sometimes used in vaccines) causes autism.

There’s also research to back up Offit’s skepticism about changing minds. In April 2014, the journal Pediatrics reported a study that found that “Refuting claims of an MMR/autism link successfully reduced misperceptions that vaccines cause autism but nonetheless decreased intent to vaccinate among parents who had the least favorable vaccine attitudes.” The authors concluded that “Current public health communications about vaccines may not be effective. For some parents, they may actually increase misperceptions or reduce vaccination intention.”

Anecdotal reports in the media have described individual physicians, often pediatricians, who’ve responded to the outbreak by discontinuing relationships with parents who refuse to have their children vaccinated, because they could spread vaccine-preventable diseases.

Buttenheim acknowledges that many pediatricians are struggling with whether to exclude non-vaccinators and concludes, “There is not a right or wrong answer to that.”

“We want parents to make the right choice,” says Kaiser Permanente’s Riewerts. “We try not to be judgmental, but we also encourage them to do the right thing.” The last thing you want to do is offend parents, he says. “It really doesn’t do anybody any good.” He adds that Kaiser Permanente never turns away unvaccinated patients.

Scott Baltic is a freelance writer in Chicago, Illinois.