The effects of an ongoing measles outbreak centered in Washington state have spread well beyond the patients who’ve contracted the virus, creating logistical challenges for schools and public health officials, who’ve spent $1 million to contain the illness.
School-age vaccine mandates have been credited with practically eradicating many severe illnesses. In 2000, for example, public health officials declared that measles had been eliminated.
But some parents’ refusal to vaccinate their children—fueled by misinformation and a distrust in public institutions—has once again given those diseases a foothold in some communities as vaccination rates fall below recommended thresholds, those officials say.
Now legislators in states like Colorado, Oregon, and Washington are debating ways to reverse the trend by promoting parent education and moving to close broad philosophical and “personal belief” loopholes in state law that allow families to opt out of vaccine requirements for reasons that aren’t medical or religious.
And at the national level, lawmakers and federal agencies are calling for further research on those parents’ decisions to find ways to address their concerns, halt misinformation, and improve rates of vaccination in the future.
“There always seem to be two sides to a discussion,” Ethan Lindenberger, a senior at Norwalk High School in Norwalk, Ohio, told the U.S. Senate’s health and education committee Tuesday. “Though this is true in most instances, this is not true in the vaccine debate.”
Lindenberger’s mother refused to have him vaccinated as a child, relying largely on false information she found on the internet to support her belief that the procedure may cause autism and possible brain damage, he said.
Convinced that she was wrong, Lindenberger had himself vaccinated when he turned 18, turning to strangers on the internet for advice.
He was invited to testify before the committee as federal and state-level officials scramble to contain a public health crisis sparked in part by parents who shared his mother’s concerns.
Disruptions to Schooling
From Jan. 1 to Feb. 28, 206 cases of measles have been confirmed in 11 states, according to the most recent data from the Centers for Disease Control and Prevention.
Seventy of those cases occurred in Clark County, Wash., alone—61 of them among people who had not been fully vaccinated, the data show.
Agencies like the CDC say vaccination levels of about 95 percent of the population are needed to promote “herd immunity,” a level necessary to slow the spread of illness and to protect people who cannot be vaccinated, like infants and those with compromised immune systems.
In Clark County, about 78 percent of all public school students have received all mandated vaccines, state data show. While 5.9 percent of the county’s students claimed broad personal exemptions, only about 0.9 percent claimed a medical exemption and 0.8 percent claimed religious exemptions. To claim a personal exemption, parents simply check a box on a form. They don’t have to explain their objections or provide more specific reasons for opting out. Statewide, 88.6 percent of Washington students are fully vaccinated, data show.
“We have lost much ground,” Washington state’s Secretary of Health John Wiesman told the Senate committee Tuesday. “Urgent action is needed.”
In response, Gov. Jay Inslee has declared a state of emergency, and state and local health departments have redirected some personnel, putting 200 people to work containing the outbreak.
Parents may not immediately recognize measles, because its initial symptoms can look like a cold or more common respiratory illness. Medical professionals sometimes don’t confirm a case until appearance of a characteristic red rash.
Investigators in Clark County have tracked down each measles case, working to identify the last public places a patient may have been when that person was likely contagious, and putting those locations on a public list.
When schools are identified, administrators must start an “exclusion period” of 21 days from the last time a student with measles attended, requiring students and staff who are not completely vaccinated for any reason to stay home during that time period. That prevents students who may be contagious but not yet showing signs of the illness from passing it on to their peers.
In the Vancouver, Wash., district, a total of 138 students had to stay home from three schools because of potential measles exposure, officials reported. That’s about 7 percent of the three schools’ combined enrollment.
In the neighboring Evergreen district, 293 unvaccinated students had to sit out of six schools, about 6.5 percent of their combined enrollment, and one of those schools had two separate exclusion periods, district spokesperson Gail Spolar said.
The exemption forms that parents submit to schools include a warning that their child may be required to stay home if there is a risk of exposure, she said.
“We simply can’t have these children in school if there’s a risk of spreading measles,” Spolar said. “But it’s a small percentage of our students when you look at our district in entirety.”
For the affected children, though, even a week of missed classes can be a substantial setback, especially as schools across the country renew their focus on lowering rates of absenteeism.
Evergreen has one-to-one computing in middle and high schools, allowing secondary students to complete work at home during exclusion periods, Spolar said. And teachers have sent materials home to help keep younger students on track.
Teachers and staff also had to provide proof of vaccinations. For those who could not do so, a local clinic expedited blood tests that measure titers, or the concentrations of antibodies remaining in their bloodstreams, from previous vaccines.
The district worked to quickly communicate with parents after each potential exposure notice. Signs posted outside of affected schools warn visitors at schools where unvaccinated children were required to stay home.
“Because of the widespread impact it’s had in this community, after the initial exposures, people are really aware,” Spolar said.
As the outbreak continued, Washington lawmakers debated a measure to eliminate vaccine exemptions for personal reasons—the broadest and easiest way for parents to opt their children out of the requirements. Lawmakers in neighboring Oregon and in Colorado are considering similar measures.
Seventeen states have personal or philosophical vaccine exemptions, which provide greater latitude for avoiding vaccines or for rejecting state-mandated vaccine schedules than religious or medical exemptions. Three states—California, Mississippi, and West Virginia—allow only medical exemptions, which public health researchers have credited with raising vaccination rates in those states.
California lawmakers eliminated the state’s philosophical exemption option in 2015 after a measles outbreak linked to Disneyland sparked one of the worst years for the disease in recent records.
In 2017, the California Department of Public Health found that the rate of kindergartners who had proof of meeting all vaccine requirements rose from 92.8 percent to 95.6 percent in the first year after the exemption ended.
In Washington state, parents must receive counseling from a physician before opting out of requirements, so that they are informed of the risks. Even so, public health officials say too many choose not to vaccinate, and the situation is particularly problematic in some areas where as many as 40 percent of students aren’t fully immunized.
“Those situations are tinder boxes just waiting to go up in flames,” Wiesman, the state’s health secretary, told state lawmakers at a packed public hearing last month.
At that hearing, 886 people signed up to weigh in on the proposed bill, most of them in objection. An audience largely filled with opponents laughed at times as supporters like Wiesman testified.
Some critics of the proposal said it is too difficult to obtain medical or religious exemptions, some said concerns about measles had been overblown, some said the risks of vaccines have not been fully explored, and others expressed a fundamental belief that the government shouldn’t be able to mandate medical procedures.
Such viewpoints have spurred some lawmakers in states like Arizona to consider loosening vaccine requirements.
“This bill is not a magic wand,” Karl Kanthak, president of the Mt. Pleasant school board, told Washington lawmakers. “It will not get most of these families to begin vaccinating. That’s not going to happen.”
Among Mt. Pleasant’s students are “refugees” whose families relocated from California after the state tightened its requirements, he said.
Even as lawmakers continue debates about mandates, others promote parental education and combatting disinformation to raise vaccination rates.
Much of that disinformation is based on a discredited study that linked vaccines to autism.
On Monday, the American College of Physicians released a major study, tracking 10 years of data on all children born in Denmark, concluding that the measles, mumps, and rubella vaccine does not trigger autism or increase a child’s risk of being diagnosed. That same day, the American Academy of Pediatrics publicly called on Google, Youtube, Facebook, and Pinterest to continue efforts to slow misinformation on their platforms.
Lindenberger, the student who got vaccinated on his own, urged federal lawmakers not to vilify parents like his mother.
“This may seem to be in malice because of the dangers not vaccinating poses, but my mother came from a place of love and concern for her children,” Lindenberger said.
He urged federal officials to explore how and why misinformation spreads. He also urged parental education campaigns to mirror the style of the information his mother is drawn to—information that relies on personal stories as much as scientific data.
Oscar Abalahin has one such story. His son, Jaxon, died in 2008, years after contracting subacute sclerosing panencephalitis, a rare form of brain inflammation linked to the measles virus, Abalahin told Education Week.
Jaxon had measles as an infant, when he was too young to be vaccinated himself. The brain disease came a few years later, stunning his parents.
They now run an organization committed to finding ways to treat the illness, to encourage parents to vaccinate, and to make the public aware that measles has the potential for deadly effects that extend well beyond the initial illness.
Abalahin doesn’t engage in political debates about state vaccine policies, but he hopes to see parents’ minds changed by the thoughtful spread of accurate information.
“To myself and my wife, when we see these things happening to our kids in the U.S.—things that can be prevented—it just breaks our heart,” he said. “There are still a lot of folks out there who feel that the immunization does more harm than good. That’s the opposite side of what we are looking at, that it does more good than harm.”
A version of this article appeared in the March 13, 2019 edition of Education Week as A Fight to Halt Misinformation and Boost Vaccinations