Controlling Measles in the US Not as Easy as Tweaking Vaccine Exemption Laws

With 6 ongoing outbreaks, individual cases reported across 10 states, and the US Food and Drug Administration (FDA) commissioner contemplating federal intervention, measles remains at the forefront of the collective consciousness.

Although it was considered eliminated in the United States in 2000, the current outbreaks are largely linked to international travelers bringing back the disease, which then spreads through pockets of unvaccinated people or communities, according to the US Centers for Disease Control and Prevention.

The issue in the United States comes down to vaccination coverage, and the exemption rules that vary from state to state. Currently, 17 states allow philosophical exemptions from vaccination due to personal, moral, or other beliefs, according to data from the National Conference of State Legislatures, and 48 states allow exemptions on a religious basis.

FDA commissioner Scott Gottlieb, MD, suggested on national television last week that the federal government may have to intervene if states continue to allow vast nonmedical vaccination exemptions.

"Some states are engaging in such wide exemptions that they're creating the opportunity for outbreaks on a scale that is going to have national implications," he said in an interview with CNN. “[If] certain states continue down the path that they're on, I think they're going to force the hand of the federal health agencies.”

xWhy the MMR vaccine? Measles is not a childhood right-of-passage but a feared and extremely contagious malady. Measles is caused by an airborne virus and is so contagious that if one person has it, 9 out of 10 people exposed and unvaccinated will get it https://t.co/PQfoYfUSXo.

— Scott Gottlieb, M.D. (@SGottliebFDA) February 24, 2019

Washington state, where there are 65 cases of measles in Clark County and 1 in King County, currently allows for religious and philosophical exemptions. But just last week the state Senate Health and Long Term Care Committee advanced a measure that would nix the philosophical exemption on personal grounds for children’s school vaccinations, The Associated Press reported.

Scott Lindquist, MD, the Washington Department of Health epidemiologist for communicable diseases, told Contagion^® that the legislation would be a good start, but more action is needed to contain the issue of infectious disease outbreaks.

“I think a lot of people like to make a very complex issue simple,” Dr. Lindquist said. “Washington state supports legislation where we’re trying to remove philosophical or religious exemptions, leaving medical in place. But that in itself is only a small piece of this. There’s a lot to be done to raise community awareness, raise vaccination or, even from a national level, should the US be involved in these large outbreaks globally? It’s a lot more of a complex picture than just excluding kids from school.”

Proposed legislation in places like New Jersey and Oregon—each of which has seen cases of measles this year—also seeks to either tighten religious exemptions or eliminate philosophical ones entirely.

“HB 3063 is an evidence-based approach to protecting the public from health risks posed by communicable diseases, especially those faced by vulnerable children, pregnant women, people with compromised immune systems, and older adults,” the Oregon Health Authority said in a statement to Contagion®, citing a bipartisan bill proposal that would remove nonmedical exemptions for children’s school vaccinations.

But what can be done in the meantime as those proposals weave their way through an often tangled legal system?

In Oregon, public health officials are in regular communication with known unvaccinated contacts of the measles cases encouraging these individuals to be on the lookout for development of symptoms and to stay at home at the first sign of illness, as well as employing rapid, state-of-the-art testing for high-likelihood cases.

In New York, which is experiencing its largest measles outbreak in decades with 149 confirmed cases in 2 counties, public health officials employ school exclusions to drive vaccination rates.

"School and daycare exclusions have been very effective at motivating parents to agree to get their children vaccinated with MMR," Jill Montag, a spokesperson for the New York State Department of Health, told Contagion®. "Since the outbreak began, approximately 6000 unvaccinated students in more than 60 schools or daycares have been excluded. However, many of them have subsequently been able to return to school due to having been vaccinated."

Dr. Lindquist and his colleagues at the Washington Department of Health have had some success with their “isolate and quarantine” response to reported cases of measles.

“Early in the outbreak, it’s hard to get a handle on this but, at this point, most of our recent cases a quarantine would be developed so there were a lot less public exposure sites. These methods of isolation and quarantine do appear to be slowing down the exposures,” he said. “A lot of the debate around vaccines is really very contentious. Nobody wants their kids to be harmed; that’s clear. So we need to find some common ground here to help control this outbreak that isn’t one side against the other.”