18 Anti-vaccine Activism in 2018 and 2019
The year 2018 saw a 30 percent increase in measles cases worldwide,1 from nineteen cases per million to twenty-five cases per million, attributed by health professionals to the effects of the anti-vaccine movement.2 That same year also saw over one hundred thousand measles-related deaths worldwide. While 95 percent coverage is believed to be required to prevent outbreaks, global coverage has stalled at 85 percent and is lower in some regions. Figure 18.1 shows how measles cases in 2018 and early 2019 have increased compared with previous years.
The return of measles to the United States: the year 2019 saw a measles outbreak in the United States, with more cases than in previous years, which has to be partially attributed to the anti-vaccine movement. Data from the CDC, www.cdc.gov/measles/cases-outbreaks.html.
Losses such as these should also be considered in the context of gains. More children than ever received the DTP vaccine in 2017; the number of undervaccinated children in the world has decreased in the last decade; and hundreds of thousands to millions of lives have been saved by vaccination programs. Since 2010 the percentage of children receiving the second dose of the measles vaccine has risen from 39 percent to 67 percent in 2017. Although polio was targeted for elimination in 2015, and still had three dozen new wild cases in 2018 and is unlikely to be fully eliminated by 2020, it is still nearing elimination.
In November 2018 an outbreak of chickenpox, affecting thirty-six students, occurred in North Carolina at a Waldorf School. This school had one of the lowest vaccination rates in the state, with nineteen of twenty-eight students in the kindergarten class having received religious vaccine exemptions.3 Waldorf schools often have concentrations of undervaccinated children. In 2015 Austin Waldorf School in Travis County, Texas, had the second highest exemption rate in Texas at 48 percent.4 Lake Champlain Waldorf School in Vermont had only a 50 percent vaccination rate.5 A Belmont Heights, California, Waldorf School had only 20 percent of its students up to date with vaccinations.6 And in the Seattle school district, a Waldorf School had the highest vaccine-exemption rate, 40 percent.7
Rockland County, New York, is experiencing an ongoing measles outbreak with hundreds of cases so far (figure 18.2),8 the outbreak was traced to an unvaccinated child who had traveled to Israel where more than 1,300 measles cases occurred in 2018.9 In Europe more than 41,000 people were infected with measles in the first half of 2018.10 The hardest hit country was Ukraine, with over 20,000 cases. In February 2019 a measles outbreak occurred in Clark County, Washington, where a medical emergency was declared after 49 cases occurred. In Clark County the measles-vaccination rate was only 78 percent.11 This has led to a bipartisan effort in the Washington legislature to eliminate personal and philosophical exemptions in that state. Recently several states, including Maine and Washington, have passed legislation making it more difficult to obtain exemptions.
The 2018 and 2019 measles outbreaks: Worldwide measles cases increased in 2019 compared with 2018, likely partially due to the effect of the anti-vaccine movement. Data from the WHO.
Outbreaks are most likely to occur when vaccination levels fall below that necessary for herd immunity. When enough members of a population are immune to a disease, the probability of a person who is not immune coming into contact with a person who is infectious goes down. Immunity can be acquired through vaccination or through infection and survival. The fraction of a population that must be vaccinated to stop the spread of a disease can be calculated as 
, where qc is the herd-immunity threshold, and R0 is the basic reproductive number of the disease, indicating the number of people someone with the disease is likely to infect. If a vaccine is less than 100 percent effective, then we must take that into account when calculating the vaccine coverage necessary to achieve herd immunity. This necessary vaccine coverage, Vc, can be calculated as 
, where E is the effectiveness of the vaccine. The measles vaccine is 97 percent effective but the R0 of measles is very high. The estimate for the R0 of measles is often cited as 12 to 18, but estimates are higher than this.12 Regardless, this means that the vaccine coverage necessary to protect a population from measles ranges from 95 percent to 98 percent.
Measles vaccine coverage remains steady at 85 percent worldwide, which is far from achieving the goal of immunization levels at or above the critical threshold for herd immunity, and is responsible for the 30 percent spike in measles in 2018. Even the 91 percent coverage in the United States is inadequate to prevent the spread of measles in the population. Some cannot afford or access health care, but those who can and choose not to contribute to the population’s immunity increase its susceptibility to outbreaks. Opposition to vaccination contributes to these numbers. Moreover, these estimates assume a homogenous population. Enclaves such as Waldorf schools can harbor rates of vaccine coverage far lower even than the population average and thus are particularly dangerous for the immune compromised and others with legitimate medical reasons for which they cannot be vaccinated.
In 2017–2018 the influenza season was at high severity across all age groups. According to the CDC, 185 children died from influenza.13 There were over 80,000 flu-related deaths in the United States, making it the most deadly flu season in a decade.14
Meanwhile, anti-vaccine activists have continued to try new strategies. In September the organization Learn the Risk put up a billboard in Kansas City with the words “As a nurse I was never taught vaccines can kill until my son was a victim.”15 In August 2018 an anti-vaccine nurse made news when she used social media to discuss a measles patient under her care, stating that seeing the symptoms helped her to understand why people vaccinate but that she would continue to oppose vaccination. She was subsequently fired from Texas Children’s Hospital for revealing confidential patient information online.16 Rallies have been held by anti-vaccine activists in some of the areas hardest hit by the 2019 measles outbreak.
In Italy the governing party of the League and the Five Star Movement were elected promising to oppose mandatory vaccination. Italy’s health minister allowed parents to self-certify that their children had been vaccinated. The Italian parliament has stated that proof of vaccination has only been delayed.17 In September 2018 the coalition scrapped its vaccination reforms. As the European measles outbreak continued into November 2018, the Italian coalition government’s health ministry called for widespread vaccination against measles.18 Adding to this confusion, in early December, the health minister fired the commission of health experts that in November had recommended widespread vaccination.19
In Germany in 2019, there was one of the highest rates of measles in Europe with more than six hundred cases. Subsequently, the German government has made plans to institute significant fines for parents who do not vaccinate.20 These plans are contingent on action by the German parliament.
The election of explicitly anti-vaccination political parties in Italy may be unprecedented in an explicitly anti-vaccine political party coming to power, an inversion of the usual relationship between establishment health authorities and antiestablishment anti-vaccine activists, and is particularly ill-timed given the current outbreak of measles.
In twelve of eighteen US states that track nonmedical vaccine exemptions (NMEs) rates of NMEs rose in 2018, part of an overall upward trend since at least 2009;21 however, in several states the rise in NMEs in the early half of the decade has leveled off. This is despite educational programs in some states requiring parents to watch videos or complete an educational module before obtaining an NME.
Figure 18.3
Time from the introduction or discovery of a vaccine against a variety of infectious diseases to the last endemic case of that disease in the United States.
Recent data has also suggested a change in the political ideology of anti-vaccine activists. A 2018 internet survey including questions about political polarization and intent to vaccinate found a weak correlation between conservative beliefs and lack of intent to vaccinate.22 This contrasts with prior studies that have shown no link between political affiliation and intent to vaccinate.
On balance, the present state of public health efforts and anti–public health efforts is a mix of both good and bad news. Vaccine coverage continues to increase, but not fast enough to prevent outbreaks of measles. Nonmedical exemptions rose but plateaued, and anti-vaccine activists have continued to invent new ways to prevent immunization, frighten the public, and push for bad legislation.
Notes
1. “‘Anti-vax’ Movement Blamed for 30 Per Cent Jump in Measles Cases Worldwide,” SBS News, November 30, 2018, www.sbs.com.au/news/anti-vax-movement-blamed-for-30-per-cent-jump-in-measles-cases-worldwide.
2. World Health Organization, “Measles Cases Spike Globally due to Gaps in Vaccination Coverage,” November 29, 2018, www.who.int/news-room/detail/29-11-2018-measles-cases-spike-globally-due-to-gaps-in-vaccination-coverage.
3. L. Wamsley, “Chickenpox Outbreak Hits N.C. Private School with Low Vaccination Rates,” NPR, November 20, 2018, www.npr.org/2018/11/20/669644191/chickenpox-outbreak-hits-n-c-private-school-with-low-vaccination-rates.
4. M. Smith, A. Daniel, and R. Murphy, “See Vaccine Exemptions in Texas by School District,” Texas Tribune, February 5, 2015, www.texastribune.org/2015/02/05/school-vaccine-exemptions-high-pockets-texas/.
5. “Vermont Schools Report Low Vaccination Rates,” Burlington Free Press, February 5, 2015, www.burlingtonfreepress.com/story/news/local/2015/02/05/vermont-schools-vaccination-rates/22945035/.
6. G. Yee, “Waldorf School in Belmont Heights Reports Low Vaccination Rate,” Press Telegram, January 24, 2015, www.presstelegram.com/health/20150124/waldorf-school-in-belmont-heights-reports-low-vaccination-rate.
7. G. Balk, “Vaccine Exemptions Exceed 10% at Dozens of Seattle-Area Schools,” Seattle Times, February 6, 2015, http://blogs.seattletimes.com/fyi-guy/2015/02/04/vaccine-exemptions-exceed-10-at-dozens-of-seattle-area-schools/.
8. R. L. Goldblatt, “Rockland Measles Outbreak: New Vaccine Clinic at Palisades Center, 91 Cases Reported,” Rockland/Westchester Journal News, December 6, 2018, www.lohud.com/story/news/local/rockland/west-nyack/2018/12/06/rockland-measles-outbreak-new-vaccine-clinic-palisades-center/2225136002/.
9. Tamar Pileggi, “Vaccination Campaign Launched in Orthodox Neighborhoods amid Measles Outbreak,” Times of Israel, November 4, 2018, www.timesofisrael.com/vaccination-campaign-launched-in-orthodox-neighborhoods-amid-measles-outbreak/.
10. Z. Kmietowicz, “Measles: Europe Sees Record Number of Cases and 37 Deaths So Far This Year,” BMJ 362 (2018): k3596.
11. K. Johnson, “‘A Match into a Can of Gasoline’: Measles Outbreak Now an Emergency in Washington State,” New York Times, February 6, 2019, www.nytimes.com/2019/02/06/us/measles-outbreak.html.
12. F. M. Guerra, S. Bolotin, G. Lim, J. Heffernan, S. L. Deeks, Y. Li, et al., “The Basic Reproduction Number (R0) of Measles: A Systematic Review,” Lancet Infectious Diseases 17 (2017): e420–e428.
13. CDC, “What You Should Know for the 2017–2018 Influenza Season,” November 2, 2018, www.cdc.gov/flu/about/season/flu-season-2017-2018.htm.
14. D. G. McNeil Jr., “Over 80,000 Americans Died of Flu Last Winter, Highest Toll in Years,” New York Times, October 1, 2018, www.nytimes.com/2018/10/01/health/flu-deaths-vaccine.html.
15. Nick Sloan and Caroline Sweeney, “Billboard with ‘Vaccines Can Kill’ Message Goes Up in Kansas City,” KCTV5, September 25, 2018, www.kctv5.com/news/billboard-with-vaccines-can-kill-message-goes-up-in-kansas/article_f428826c-c10c-11e8-9401-3730f9178bec.html.
16. C. Domonoske, “Texas Nurse Loses Job after Apparently Posting about Patient in Anti-Vaxxer Group,” NPR, August 29, 2018, www.npr.org/2018/08/29/642937977/texas-nurse-loses-job-after-apparently-posting-about-patient-in-anti-vaxxer-grou.
17. F. De Benedetti, “How the Anti-vaxxers Are Winning in Italy,” Independent, September 28, 2018, www.independent.co.uk/news/world/europe/anti-vaxxers-italy-vaccine-measles-epidemic-europe-us-vaccination-global-health-security-agenda-a8560021.html.
18. “Italy’s Populist Coalition Renounces Anti-Vaccination Stance amid Measles ‘Emergency,’” Daily Telegraph, November 15, 2018, www.telegraph.co.uk/news/2018/11/15/italys-populist-coalition-renounces-anti-vaccination-stance/.
19. “Italy’s Coalition Spreads Confusion over Vaccinations by Sacking Commission of Health Experts,” Daily Telegraph, December 5, 2018, www.telegraph.co.uk/news/2018/12/05/italys-coalition-spreads-confusion-vaccinations-sacking-commission/.
20. R. Picheta, “German Government Backs Mandatory Vaccinations for All Schoolchildren,” CNN, July 17, 2019, www.cnn.com/2019/07/17/health/germany-measles-mandatory-vaccine-scli-intl/index.html.
21. Global Biodefense Staff, “The State of the Antivaccine Movement in the United States,” June 28, 2018, https://globalbiodefense.com/2018/06/28/the-state-of-the-antivaccine-movement-in-the-united-states/.
22. B. Baumgaertner, J. E. Carlisle, and F. Justwan, “The Influence of Political Ideology and Trust on Willingness to Vaccinate,” PLoS One 13 (2018): e0191728.