Measles cases are resurgent. So why are vaccines controversial?

There was a time when the arrival of summer sparked dread in American parents, when danger lurked in swimming pools and movie theaters, and when tens of thousands of children developed the weakness and paralysis of polio.  

It was a time when hospitals set up rows of iron lungs to help stricken children breathe, when doctors fitted children with crutches and leg braces to help them walk, and when hundreds died.  

That was the polio epidemic.  

But that was long ago, before what seemed like a miracle banished polio —  or “infantile paralysis” — from the country. The miracle was a vaccine, and its advent in 1955 made its developer, Jonas Salk, a national hero.  

Today, polio is a distant memory — perhaps too distant for those who say vaccinations are unsafe and that the risk of vaccination is not worth the protection it confers.   

But polio is not the only curse to have been banished by a vaccine.  

Smallpox also has been eradicated — the first disease eliminated worldwide through vaccination efforts. 

Measles, too, could have gone the way of polio and smallpox. But this year its spread among pockets of under-vaccinated people around the United States has led to the highest number of cases since the federal government declared it eliminated here in 2000.  

“The longer these outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States,” the federal Centers for Disease Control warned this week, as it reported a record 695 cases in 22 states.  

Outbreaks in Rockland County and Brooklyn, where 200 and 390 cases, respectively, had been confirmed as of Wednesday, are among the largest and longest lasting in the past two decades, the CDC said. The outbreaks in New York and New Jersey — with 14 confirmed cases this year — are almost entirely among Orthodox Jews.

This week California officials also declared new outbreaks, in Los Angeles and Sacramento. Michigan has a record 43 cases, including more than 30 — mostly among adults — from a single Israeli traveler. 

The highly contagious virus has been imported via travelers from countries where the disease is uncontrolled, such as Israel, the Philippines and Ukraine. Globally, the World Health Organization says measles cases are up 300 percent, and it has labeled “vaccine hesitancy” one of this year's  top ten global health threats.   

How did vaccines, which have saved millions of lives over the past 70 years and inspired hope for future protection against modern scourges like Ebola and Zika, become controversial? How did one of the greatest public health achievements in history come to be seen, by some, as a threat?  

The resurgence of measles is “an outrageous self-inflicted wound for our nation,” Dr. Peter Hotez, a pediatrician, vaccine expert and founder of the National School of Tropical Medicine at Baylor College of Medicine, tweeted this week as the numbers from the CDC were released.  

He attributed the surge in infections to strong — and often unopposed — anti-vaccination messages on social media, a lack of effective pro-vaccine advocacy, and weak state legislatures that have allowed parents to easily obtain vaccine exemptions.  

Opposition to vaccinations in the United States by a small but significant subset of parents now threatens to undermine the public-health gains achieved. 

Fear factor is gone

The roots of the anti-vax movement are varied and hard to counter. 

For one thing, parents today generally haven’t seen the painful or fatal consequences of the targeted diseases. 

“When I was growing up, everybody got measles — and some people died,” said Dr. Michael Gochfeld, professor emeritus at Rutgers University’s Environmental and Occupational Health Sciences Institute. As for polio, “It was lurking at your doorstep — you didn’t go out in the summer."

"There was fear, and when the vaccines became available there was virtually no opposition,” Gochfeld said.

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Today, he said, the infectious diseases of the past aren’t so feared, and parents who feel uncertain about vaccines see less urgency in protecting against those contagions.  

Influential — but discredited — study

In addition, some parents believe there is a link between the vaccines young children receive and the development of autism, based on a widely circulated but completely discredited study.  

British researcher Andrew Wakefield opened a Pandora’s box in 1998 with his study, published in the British medical journal, the Lancet,  linking the onset of autism in 12 children with the vaccine for measles, mumps and rubella (MMR). The study was declared fraudulent in 2010 and retracted by the journal, and Wakefield’s license to practice medicine was revoked.

Nevertheless, the scare has persisted. 

Given the schedule of childhood vaccines and the age at which autism is usually diagnosed, almost inevitably a child who is diagnosed with autism had recently received a vaccine, Gochfeld said, “and so it’s easy to make a connection that’s false or misleading.” 

There is no evidence that vaccines cause autism, a developmental disorder whose characteristic repetitive behaviors and loss of social interaction or communication appear when children are toddlers or preschoolers.

Nor do vaccines contain toxic chemicals, the director of the CDC, the surgeon general of the United States, and the assistant secretary of Health and Human Services have stated.  

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But the increasing prevalence of autism in the United States — a trend for which researchers have no complete explanation — presents a challenge for public-health messaging. A single, heartfelt parent's account of a child being diagnosed with autism after receiving a vaccine is difficult to counter, even though one did not cause the other.  

Government mistrust

Another factor at play is that many who oppose vaccinating their children harbor a fundamental mistrust of the government and believe it should stay out of their child-rearing decisions. 

“A deep-seated resentment of state power courses through the [anti-vaccination] movement,” said Julia Bowes, a historian who has studied the politics of child-rearing in the United States. “The heavy-handedness of state policies gets people’s backs up,” she said, whether applied to busing, school prayer or mandatory vaccines. 

Today’s resistance to vaccination policies has deep historical antecedents, she said. In 1911, a protest against a compulsory smallpox vaccination law in Montclair led 350 families to withhold their children from school and threaten to move them to a more lenient school district, she learned while researching her dissertation at Rutgers. They won — the law was rescinded. 

It’s no coincidence that today’s pockets of unvaccinated children are found in communities where public-school education is rejected in favor of private schools or home-schooling. New York City’s measles cases have spread among students at some ultra-Orthodox yeshivas and day care centers. The successful lawsuit against Rockland County’s emergency decree banning unvaccinated children from schools and public spaces was filed by parents of children at the private Green Meadow Waldorf School.  

Others hold a worldview that is skeptical of science and expertise itself, whether in medicine, climate change or other realms. 

This "post-modern view of science” rejects biomedical and scientific facts in favor of personal experience and interpretation, wrote Anna Kata, a health anthropologist and researcher at McMaster University in Canada. They doubt studies of vaccine safety or efficacy and give more weight to real — though rare — vaccine side effects.  

Role of social media

These trends have been amplified by social media.  

The New York outbreaks were made worse because “some organizations are deliberately targeting these communities with inaccurate and misleading information about vaccines,” the CDC said Wednesday. Booklets and fliers questioning the safety of vaccines have been circulated, undermining the efforts of Orthodox rabbis and school leaders to quell fears about vaccination.  

Facebook and Google both were called out earlier this year for serving up false information in searches and spreading misinformation. Women of childbearing age in Washington State reportedly were targeted on Facebook with anti-vax messages after that state’s governor declared measles in one county a public health emergency.  Both companies said they would take steps to direct users to more credible sources, but did not completely remove problematic content.   

U.S. Rep. Adam Schiff, a California Democrat, also chided Amazon for accepting paid advertising from anti-vaccine groups. 

Russian Internet trolls and bots (one used the hashtag #VaccinateUS) have also “weaponized” public health messages to sow discord among the American public, using vaccines as a wedge issue, researchers found.  

By issuing both anti- and pro-vaccine tweets and memes they attempt to make it seem vaccine safety and efficacy are open to debate and create mistrust of public health institutions and experts.  

Easier to get exemptions 

This proliferation of misinformation has been coupled, in many states, with easy access to vaccine exemptions. Seventeen states now allow philosophical exemptions to mandatory vaccines for public school students, according to the National Conference of State Legislatures, and almost all allow religious exemptions — some of them quite lax.

“When the state suddenly made it easier to get a religious exemption by just checking the box, people found it more convenient,” said Peter Wenger, a pediatrician specializing in infectious diseases at St. Peter’s Healthcare System in New Brunswick and chair of the New Jersey Immunization Network. “It was a matter of convenience for a lot of people.” 

New Jersey asks no questions — and requires no outside verification — when parents say their religious tenets lead them to oppose vaccinating their children.  

In fact, some children cannot be vaccinated for medical reasons — and all states allow medical exemptions. Babies too young to be vaccinated are also vulnerable.  

These children rely on others to get protection, in a concept known as herd immunity. If the whole herd is immune, the disease will not spread and those who are vulnerable will not be exposed. For measles, scientists say 93 to 95 percent of the population must be immune to protect the herd.  

Under-vaccinated pockets

"We've seen high and stable immunization rates for several years,” the CDC said.  But there are pockets — both urban and rural — where the unvaccinated population is significantly higher than the average.  

Once measles takes hold “in an under-vaccinated community, it becomes difficult to control the spread of the disease,” the agency said.  

Fifteen metropolitan areas and 10 rural counties were identified by researchers last year with higher rates of non-vaccinated kindergarten children. They include cities in Washington, Oregon, Utah, Texas, Missouri, and Michigan, and counties in Idaho, Wisconsin and Utah. 

“This current outbreak is deeply troubling," said Robert Redfield, the CDC director, on Thursday. He called upon health care providers "to assure patients about the efficacy and safety of the measles vaccine" so that measles can once again be eliminated in the United States. 

Alex Azar, secretary of Health and Human Services, has been the highest ranking Trump administration official to speak about the outbreaks. 

"The suffering we are seeing is avoidable," he said. “Vaccines are a safe, highly effective public health solution that can prevent this disease.”