In the last week, I have been watching with interest the news coverage of the measles outbreak in Washington state. Given last month’s article on the importance of the influenza vaccine and Partners’ policy for employees, this new measles crisis made me wonder how this kind of outbreak happens.
Measles was thought to be eradicated from the United States in 2000. The vaccine had been widely accepted in the U.S. population and after two doses there is a 97% effectiveness in its prevention. In many states, measles vaccination is required to be enrolled in nursery school or to attend public schools. So what changes made that environment conducive for this outbreak to occur?
We know that measles is a contagious virus that spreads through the air via coughing and sneezing. Once infected, someone can be contagious for up to four days before they display symptoms and for four more days after symptoms appear. The virus can live for almost two hours in a room where an infected individual has been. One or two out of every 1,000 children who get measles will die from complications, according to the U.S. Centers for Disease Control and Prevention.
The first case in the Washington outbreak has been traced to an international traveler in Clark County who had contact with community groups with low vaccination rates. Washington Department of Health officials identified numerous places where people may have been exposed to the virus. Hawaii also reported two cases of measles in travelers who were infected in Washington before their visit to the Big Island.
Clark County is on the border of Washington and Oregon, with both states allowing the exemption from vaccination for personal reasons beyond the typical medical or religious exemption. In Washington, almost 8% of the children are not vaccinated. But cases of measles have not only occurred in Washington and Hawaii, but also in Oregon, New York, Pennsylvania, Connecticut, Colorado, California, and Georgia. Officials at the CDC and state health departments expect to see more.
So why are we seeing a resurgence of measles and some other communicable disease? The World Health Organization describes the concept of vaccine hesitancy as a global problem that requires monitoring. The WHO describes vaccine hesitancy as the delay in acceptance or refusal of vaccines despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place, and vaccines. It includes factors such as complacency, convenience, and confidence.
As health care providers, we have an important role to protect our patients and our communities. Recognizing the complexity of the determinants in making the decision about vaccination is the first step. Is there a fear of the sequelae of vaccines or is the hesitancy related to difficulty in getting access to vaccinations? Are there equity issues involved?
Solutions to address this problem should be multifaceted and local to be most effective. And health care providers need to be informed with data that can speak to the consequences of the decisions that are made. We are the most trusted advisors in communities related to these health care decisions and have a critical role to play in reducing the spread of communicable disease.
For more information on the issue and management of vaccine hesitancy, I invite you to read this 2014 WHO report.