Anti-vax: It’s worse than you think

Uncle-Sam-Measles

In a world where the MMR vaccine exists, there’s no good reason to get the measles (washingtonexaminer.com).

Not everything retro is chic. Especially when it comes to preventable contagious diseases.

A small but growing number of parents disagree, though. Through their actions — or their inactions, as it were — these families are resuscitating already cured diseases dreaded by our grandparents. And as these parents question the value of lifesaving vaccines, whether in the name of parents’ rights or opposing big pharma and its chemicals, all of our children will be affected.

What’s more, a dive into the numbers shows the risk of a new crisis is more immediate than we might think. And that crisis could very well start in Washington, D.C.

Measles is a live risk in the early 21st century, much as it was in the first half of the 20th. Between Jan. 1 and June 27 of this year, the Centers for Disease Control and Prevention reports, there were 1,095 new cases of measles across 28 states. Lest anyone think this is no big deal, the buttoned-down CDC’s website practically trumpets, “This is the greatest number of cases reported in the U.S. since 1992 and since measles was declared eliminated in 2000.”

That declared elimination, which represented a triumph of science and modern medicine, could well be toppled in short order. And that should concern us all.

There has been much discussion about the measles outbreak that erupted in New York last fall, but what about the rest of the country? Contagious diseases, after all, have a way of traveling. As the mother of young children in the Washington area, I wondered about the risk of further potential outbreaks, especially here in the nation’s capital. Having now asked plenty of questions, I’d say that if you’re a parent with young ones at home, this is not an idle concern.

According to Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine and co-director of Texas Children’s Hospital Center for Vaccine Development, “The major risk is importation of measles from Europe through Dulles Airport, and if there’s a tightly knit group that’s unvaccinated, that could be a problem.” Recall Disneyland’s 2015 outbreak, which infected residents not only of other states, but also other countries.

Measles is no joke. It’s clearly dangerous for children under 5 years old, the immuno-compromised, and pregnant women. But anyone unvaccinated and adults over 20 also remain at risk. The CDC reports that about 20% of people who contract measles will be hospitalized. About 10% of children with measles will develop ear infections and can suffer irreparable hearing loss. Severe complications for adults and children include pneumonia and brain swelling, the latter of which can leave children deaf or with an intellectual deficit. “ Nearly 1 to 3 of every 1,000 children” with measles die from measles-related complications, and pregnant women are at risk for premature birth or delivering a baby with low birth weight. There are also long-term risks, including death via disease of the central nervous system 7-10 years after a person has seemingly defeated measles.

Measles is airborne, making it easily communicable. According to the CDC, “Measles is so contagious that if one person has it, up to 90% of the people close to that person who are not immune will also become infected.” That’s especially problematic for populations that live in close quarters, socialize frequently, and have many young children, rather like Brooklyn’s Orthodox Jewish community. So even though 94% of attendees at Orthodox schools in the Williamsburg neighborhood of New York City and 97% of those students in Borough Park were vaccinated against measles, the disease still spread in those neighborhoods.

Those vaccination numbers debunk the assumption, however, that the insular Hasidic community leans anti-vaxxer. They don’t, and there’s no reason they should, since Judaism in no way prohibits vaccinations, nor is there any cultural norm whatsoever within Judaism to distrust modern medicine.

For everybody else, it should be instructive that measles can overtake even a community with high vaccination rates. That should chasten those of us who live in areas with lower levels of vaccination, and in America, those pockets are many. If everyone kept their quirky selves at home, that’d be one thing. But every summer, multitudes trek to our nation’s capital to visit national monuments, museums, and political leaders. So, when it comes to vaccination choices, what happens back home doesn’t stay home. Anything a visitor encounters in “the swamp” could become a viral souvenir.

And there’s some bad news on that front.

Washington, D.C.’s Department of Health identifies 95% as “the ideal vaccination rate for ‘herd immunity.’” If we use that as our measuring stick, a number of states fall short. According to CDC data from 2017, states as far flung as South Carolina, Ohio, Missouri, Colorado, New Mexico, and Washington all have measles, mumps, and rubella, or MMR, vaccination rates below 90%.

Vaccination rates aren’t uniform within states, of course. The public health challenge is identifying areas with lower rates of vaccination, where an outbreak could take off, much like a wildfire. The next step is understanding why numbers are lower than they should be and formulating an appropriate response.

Let’s start by considering New York City. When the measles outbreak erupted in Brooklyn last fall, New York City’s Department of Health and Mental Hygiene was able to respond because it “conducts routine surveillance for vaccine-preventable diseases, including measles,” according to a spokesman. The department’s tailored follow-up was informed by the fact the city can “look at coverage by neighborhood but can [also] look at childhood data by ZIP code and race/ethnicity when needed,” the spokesman explained.

Further, the department knew that citywide religious exemptions more than doubled between the 2014-15 school year and 2017-18, from 1.1% of students to 2.3%. Notably, New York’s state legislature recently revoked religious exemptions, leaving only medical exemptions permissible.

Religious exemptions remain legal in Washington, D.C., though. To claim such an exemption, Dr. Anjali Talwalkar, principal senior deputy director and senior deputy director of the Community Health Administration at the District of Columbia Department of Health, told me that families need not specify their religion or religious objection. They don’t even need the signature of a member of the clergy, unlike with medical exemptions, which do require a doctor’s signoff. So, perhaps it’s no surprise that the D.C. Department of Health reports that for the 2018-19 school year, 58 students in the District claimed medical exemptions, which can be either temporary or permanent, while approximately three times as many, 180 students, claimed religious exemptions.

But this is only the tip of the unvaccinated iceberg. A quick glance at the Department of Health’s records of MMR vaccination rates across schools shows a sizable gap between this tiny band of overt objectors and the number of students who don’t appear to have this common vaccination.

That brings us to the larger and more troubling piece of the puzzle. There are students whose families have not formally opted out of vaccinating but functionally seem to have done so. Even though vaccinations are legally required to attend school, there are significant numbers of children attending local schools without proof of immunization.

So, who are these students? Talwalkar told me, “No neighborhoods come to the surface as being particularly low in vaccination coverage.” However, certain schools’ vaccination rates are noticeably lower than others.

The D.C. Department of Health can sort data by ward (D.C. is composed of eight wards) or individual schools, which they divide into four categories: public, charter, private, and parochial. None of the four categories averages the preferred 95% vaccination rate, although the public and charter schools come closest, surpassing the 92% mark.

There are two public schools that clock in right about the 81% mark, Nalle Elementary School and Roosevelt High School, along with a number of others in the mid-to-high 80s. Those numbers are not good. However, it’s the private and parochial schools, where clearly not all enforce vaccinate-before-we-educate rules, that appear weakest on this front. Among parochial schools, the middle school San Miguel School doesn’t even crack the 60% mark. (Given the massive media focus on the Jewish community in New York, it may be worth noting that there are no Jewish schools on the District’s list of parochial schools.)

Among schools the District classifies as private, including a number of schools with religious affiliations, the numbers sink lower. Sankofa Fie, a school that offers support to home-schoolers, reports a vaccination rate of 33.33%. Only 37.5% of elementary students at the Dupont Park Adventist School are listed as vaccinated, and the same holds true for only 42.11% of students at the Rhema Christian Center School. Vaccination rates among elementary students at the Bishop John T. Walker School, an Episcopal school for boys from underserved communities, doesn’t even crack 64%.

At the private Edmund Burke School, which sits spitting distance from numerous embassies and has about 300 students, less than 61% of those students are vaccinated. The British International School, which educates more than 500 students, is just shy of 70% vaccinated.

Lest anyone think this problem is relegated to Washington, D.C., Hotez assured me it’s not, pointing to populous Texas. Between 2004 and the 2015-16 school year, the number of Texan students with vaccine exemptions leaped from “just under 3,000 — or 0.09 percent” to “almost 45,000 — about 0.84 percent of the state’s overall school-age population,” according to the Texas Tribune. And again, those opting out are not evenly distributed. Three of the state’s 10 largest school districts, including the Austin Independent School District, had opt-out rates higher than the state average. Two school districts in the same county as the Austin Independent School District had “exemption rates that are almost quadruple the statewide percentage.”

But back to the land of cherry blossoms. Why are Washingtonians opting out, whether actively or passively? I asked about cost, and Talwalkar replied via email that “cost has not been identified as a barrier to childhood vaccines for three reasons: 1) Under the ACA, all major insurance companies are required to cover routine childhood vaccines, 2) Approximately 98% of the District’s children are insured either through private or public insurance, and 3) For those children on Medicaid or without insurance, enrolled providers can receive and administer free vaccines from DC Health’s Vaccines for Children (VFC) Program, a federally funded program for children up to age 18.”

So if cost isn’t the issue, the explanation is less clear, in part because the D.C. Department of Health has incomplete data. It turns out the District has what amounts to a backup or double-check system in place; health officials can access vaccination information for any District student who sees a District-based doctor. However, there is no such access for students whose health providers are located outside the District. Those are the students who most need to provide their hard copy health forms to schools, and based on existing records, not all of them are.

The vaccination rates recorded in the department’s records reflect the number verified by D.C. officials. So it’s theoretically possible additional students may be current on their MMR or other vaccinations, but the department has no record of such in its electronic registry, the District of Columbia Immunization Information System. According to a spokesman for the D.C. Department of Health, the immunization information system “was custom built in 1992 and is supported by legacy software.” In fact, states’ immunization registries, which remain separate, grew out of a previous measles outbreak that lasted from 1989 to 1991 and took the lives of 89 children.

When records are incomplete, it’s difficult to tell exactly how much vaccination rates and preferences have changed. If schools had consistently enforced the vaccine requirements, it would be obvious whether a growing share of local parents oppose vaccinations, or whether they are simply forgetting to submit paperwork. Of course, any parent responsible enough to vaccinate a child is likely also responsible enough to submit the relevant health forms.

In short, as things stand, the lack of enforcement, which falls largely on individual schools, makes it difficult to know precisely how low local vaccination rates are. They might be better than official records reflect. Of course, they might well be awful, as the numbers above indicate, meaning numerous schools have long since forfeited the benefits of herd immunity.

Based on the numbers the D.C. Department of Health has, if there were a local outbreak, ground zero would likely be a private or parochial school. That complicates prevention because, as a spokesman from the Office of the Deputy Mayor for Education emailed, “Private and parochial schools have the authority to enforce vaccination policies within those school[s]. However, the District’s Department of Health has the authority to enforce only after a health emergency has been properly declared.”

And that gets to the crux of the problem. Talwalkar acknowledged there’s concern among public health professionals, especially with confirmed cases of measles in neighboring Maryland and Virginia and with the District’s being “a popular summer destination.” Toward that end, the D.C. Department of Health is focusing its summer well child campaign on immunization. However, the department continues to have zero power to enforce that message unless, or until, there’s a local outbreak.

Talk about leading from behind. As a parent, this tells me families are on our own when it comes to protecting our littlest ones. It also means that if anything is going to change, it’s on parents who support vaccination to start speaking up and insisting that schools and camps and sports leagues enforce vaccination laws. The anti-vaxxers have been plenty loud, but for the sake of community health, they shouldn’t have the last word.

This article appeared in the Washington Examiner magazine.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: