Children whose parents refuse vaccination may spread measles

by Todd Neale

Children whose parents refuse vaccinations for them provide fertile ground for the spread of vaccine-preventable diseases, an investigation of a 2008 measles outbreak in San Diego demonstrated.

Although the rate of two-dose immunization against measles was 95% in the area, a single case of measles from a 7-year-old child returning from overseas sparked an outbreak that exposed 839 people and sickened 11 other children, according to David Sugerman, MD, MPH, of the CDC’s Epidemic Intelligence Service, and colleagues.

None of the 12 children, who ranged in age from 10 months to 9 years, had been vaccinated — nine because their parents had refused the vaccine and three because they were too young, the researchers reported in the April issue of Pediatrics.

Although the virus was not spread extensively, it came at a substantial cost of $176,980 for investigation, containment, and healthcare.

In San Diego, the overall rate of vaccine refusal — predominantly because of safety concerns — was low at 2.5% in 2008, but it had been rising since 2001.

The possibility that increasing rates of intentional undervaccination could lead to a rise in outbreaks of vaccine-preventable diseases is “a monumental concern,” according to Anne Gershon, MD, a pediatric infectious disease expert at Columbia University Medical Center in New York City.

“It’s very important for parents to understand that the disease itself is always more serious than a true reaction to the vaccine,” she said in an e-mail.

The endemic transmission of measles was declared eliminated in the U.S. in 2000 because of widespread use of an effective vaccine, but the virus remains endemic in other parts of the world.

Occasionally, imported cases cause outbreaks. In 2008, there were 140 measles cases in the U.S., the largest number since 1996, when there were 508.

There are concerns that cases of measles and other vaccine-preventable diseases will continue to increase as public focus shifts from the dangers of disease to vaccine safety.

To explore the effect of intentional undervaccination on an outbreak of a vaccine-preventable illness, Sugerman and his colleagues turned to the January 2008 measles outbreak in San Diego, sparked by a 7-year-old returning from a trip to Switzerland.

The child’s parents had signed a personal-beliefs exemption to refuse vaccination for their children.

The index patient directly infected his two siblings, two classmates, and four children who were treated at the same clinic.

The index patient’s sister then infected two of her classmates. One of the index patient’s classmates infected his brother, bringing the total number of cases to 12.

One child, a 10-month-old, was hospitalized, and received IV hydration for diarrhea.

A vigorous public health response, including quarantine of exposed children who had not been vaccinated, prevented the outbreak from progressing further.

In the study area, parents who refused vaccines for their children tended to be white, well-educated, and from the middle and upper classes.

There were clusters of vaccine refusal, occurring more often in public charter and private schools, as well as in public schools in upper-class areas.

William Schaffner, MD, chair of preventive medicine at Vanderbilt University in Nashville, said in an interview that there is growing concern about these community clusters, because they create a pool of susceptible children who interact with each other on a daily basis.

Although high vaccination rates prevented the San Diego measles outbreak from extending into the general population, Schaffner said “you cannot rely upon herd immunity to protect each and every child.”

In discussion groups and surveys, most parents who refused vaccines for their children were concerned about possible adverse effects, including autism, ADD/ADHD, asthma, and allergies. They expressed skepticism about the government, pharmaceutical industry, and medical community.

In addition, “they believed vaccination was unnecessary, because most vaccine-preventable diseases had already been reduced to very low risk by improvements in water, sanitation, and hygiene and were best prevented by ‘natural lifestyles,’ including prolonged breastfeeding and organic foods,” Sugerman and his colleagues wrote.

But, according to Schaffner, parents harboring those ideas are misguided.

“There’s nothing in that sentence that is correct,” he said. “You can have the purest water, eat the most natural food, be very healthy, and if exposed to measles, your child will get measles and can get a very severe case.”

He noted that people often forget that before vaccination was introduced in the U.S. in 1963, measles killed an average of 400 children a year in the U.S.

“People don’t recognize how potentially very serious these so-called childhood infections can be,” he said.

The best way to help inform parents about the importance of vaccination for their children remains the dissemination of science-based information through the media and doctors, Schaffner said, although he acknowledged that that approach does not seem to be working.

A longer-range solution, he said, would be to make sure school health curricula contain lessons on vaccines and the diseases they prevent. Schaffner said many current curricula are deficient in this area.

“We shouldn’t be surprised that when these teenagers in a few years become young adults and parents that they’re not very educated about vaccines.”

Todd Neale is a MedPage Today staff writer.

Originally published in MedPage Today. Visit for more pediatrics news.

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  • PedDoc

    Not to mention the inability of young physicians to diagnose a vaccine-preventable illness that they have never seen. I personally have never seen measles, and I have to group multiple pediatric residents into a small room whenever we see a case of varicella so they can have an opportunity to burn the image into their minds.

    • tgottsdo

      I know… I was in Kosovo in 2005 and I told the local doctors at the “university hospital” that I had never seen a case of measles… they laughed at me.

      I have seen chicken pox and there was some H.flu around when I was in my training. I don’t recall a case of the mumps although I had it as a kid. I guess we could set up a clinic in the Seattle area to see actual infectious childhood diseases without having to go to a third world country.

  • Outrider

    This movement is also somewhat prevalent amongst my clients (I’m an equine veterinarian).

    Unfortunately, I know what a case of West Nile looks like in a horse: a lot like rabies.

    It’s simple to me: if the kids are unvaccinated without a valid medical reason, well, no school, no daycare, etc. It’s the parents’ choice. I can imagine the risk to kids with immune system disorders, HIV, chemo patients, etc. who rely upon herd immunity because they cannot safely be vaccinated. Horses unvaccinated for rabies aren’t welcome at some competitions (although there was an incident a few years ago at a major show involving a questionably vaccinated horse who did in fact have rabies), nor is this tolerated at most boarding barns because of the risk to humans and other horses. Rabies vaccine refusal is cause for me to dismiss the client from my practice (that’s the only vaccine I require). Of course, horses don’t have “rights”…

  • bg

    I read a study once that says the measles vaccines put the public more at risk than the measles. The reasoning: getting the measles gives lifelong immunity. The vaccine does not. So in the long run it is better to have a population with lifelong immunity.

    Also, did you know that highly refined peanut oil is “generally recognized as safe” and does not have to be listed as an ingredient on vaccines and other pharmaceuticals? Did you know that because of trade secret protection that it is illegal for anyone in the FDA to tell you which products have peanut oil in them?

    Did you know that there is a peanut allergy epidemic among our vaccinated children: 1 in 125 children have a possibly FATAL peanut allergy?

  • Bryan

    My kid had all the vaccinations, then had her first MMR. It made her so sick, I vowed to ignore the medical community regarding vaccination. I trusted, now I make my own decisions. Some kids get hurt by vaccines. I’m no antivaccine, I am anti vaccine injury and now realize vaccines aren’t totally safe for everyone. Mass vaccination policies without exception are the problem. Let’s vaccinate but not with a blind eye to vaccine reactions.

    • tgottsdo

      Its true… vaccines can have severe reactions. Luckily, they’re very rare. Unfortunately, we can’t tell who will get a reaction and who won’t before they get a shot. I hope your daughter is ok now and the ironic thing is that since she got the first MMR she has a pretty good chance of being immune to the disease.

  • soaringcanary

    Thank goodness some are responding to this article from the honest perspective of their intuitive research as well the hand’s-on experience with their own children. These days, when the protocol is to load our children up with close to 50 vaccine doses before they reach kindergarten, there is MUCH to be concerned about with such young immune system being over-stimulated [overwhelmed] which, in an alarming fashion has been increasing since the 70′s and is likely THE causation of so many children now living with allergy, food sensitivities and other digestive or organ [kidney/liver] disorders. I mean, no one should obediently submit to what pharmaceutical manufacturers have convinced medical students is [artificially] necessary for “herd immunity” when the best way to achieve life-long immunity is to allow the immune system to react to it [fever/build anti-bodies against] as our bodies have been capable of doing long before the advent of ‘vaccines for everything’ philosophy. At age 63, and with no vaccine exposure until age 10 [Polio], I managed to survive aggressive bouts with common measles, German measles, mumps, Scarlet Fever, flues, colds, boils, and rashes and I say this is because with each subsequent infection, the body became ‘more robust’ in its surveillance and illness resolution. With [too] many vaccines being forced upon children from their first day of life and then repeatedly through the next 5 years when young immune systems are still maturing, it makes no logical sense to endanger them with these immunological challenges. When raising my children in the early 70′s their childhood vaccine schedule was around 27 doses before age 5…and these days we are forcing those most vulnerable amongst us to endure up to 50. Intuitively, and with the increased incidence of so many now hypersensitive immune systems, the Truth is screaming for all to notice since such “herd” mentality makes NO ‘safe’ sense whatsoever.

    • tgottsdo

      Unfortunately, nothing you state in your comment is backed up by any evidence what-so-ever… of course you might not intuitively think so. The definition of intuition is, “direct perception of truth, fact, etc., independent of any reasoning process; immediate apprehension.” I might intuitively believe that infections are caused by “bad humors” in the blood that can be eradicated by bleeding. Of course before the discovery of bacteria and other causes of disease many people died this way… by bleeding to death. I’m not sure of the exact date but sometime well over a century ago we gave up on “intuition” to cure diseases and set about a method to prove actual treatments worked… its called the scientific method… today its called evidence based medicine. That’s not to say that intuition has no place in science… on the contrary, most scientific questions are based on someone asking, “I wonder if…” or “I think…” and then setting out to prove or disprove their intuition.
      Your intuition tells you that we must be overtaxing our children’s vulnerable immune system. The truth is that a child’s immune system is exposed to thousands of antigens everyday… we don’t raise our children in plastic bubbles. And to suggest that exposure to a natural disease is somehow healthier than exposure to an inactive or weakened component of that same disease is somewhat troubling. How many children would you have die in order to test your theory? In the article it stated that before the MMR vaccine was introduced in 1963 an average 400 children died per year… and that was in a smaller population. US population in 1963 was 189 million… so would you be willing to accept the 600 or so child deaths/year from measles in order for kids to be exposed to the “natural disease”. In effect by giving a vaccination you are exposing their immune systems to the disease in a controlled/safe way… its not intuitive to me that in order to make my child healthy I have to risk his life. Doesn’t the article about the outbreak in San Diego impress you as to the infectiousness of Measles? Basically, every non immunized kid those kids came into contact with got sick… and no kids who got the immunization got sick… lo and behold, the vaccine works. If one of those kids died I would be in favor of charging the parents of the index case with voluntary manslaughter…. maybe all the parents.
      Of course there are other vaccines that these kids are missing… I would be much more afraid of H. Influenza then Measles. With H. Flu you can get a throat infection so bad that your throat closes off and you suffocate, or meningitis that can leave you brain damaged or maybe just deaf…. if you survive. Why don’t we test your grandkids on your theory and put them in a room full of H. Flu to see if they survive the native/wild disease? And i guess a few kids every year with paralytic polio wouldn’t really hurt anyone… we do have all those iron lungs just sitting around gathering dust.
      What vaccines would you like to eliminate? All? some? since your upset about the number of doses maybe we should just forget everything we’ve learned over the last 30 years since you had kids and go back to 27 shots… after all… 52 shots must be worse than 27… my intuition tells me so.

  • Jill of All Trades, MD

    There have been a total of nine cases of measles reported in the state of California since January 2010 — there were only a total of nine cases in all of 2009! The California Department of Public Health just released a health advisory report, stating that many of the cases were in those with recent travel to Europe or Asia, however, some were in those children who were not vaccinated with the MMR. Last outbreak was in the early 1990’s with 17,000 reported cases that caused 70 deaths! Physicians definitely need to be on the look out for measles, and learn how it presents. It’s unfortunate that parents who do not vaccinate their kids are actually placing other children at risk as well as their own.

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