Tag: free-riders

Update on Vaccine Exemption Rates in California

Vaccination rates in California are dropping.

Wait, what?

Didn’t they recently pass a vaccine law that removed non-medical exemptions? How could vaccination rates be dropping?

Update on Vaccine Exemption Rates in California

While SB 277 did indeed remove all non-medical exemptions to getting vaccinated, some folks found a way around it. Since 2015, when it passed, some doctors are giving kids fake or unnecessary medical exemptions. These extra medical exemptions are likely making up for their previous personal belief vaccine exemptions.

The result?

It isn’t fewer exemptions since 2015.

Explain to me how it is ethical to misrepresent the rates of medical exemptions during a measles outbreak?
Explain to me how it is ethical to misrepresent the rates of medical exemptions during a measles outbreak?

While personal belief exemptions are certainly down, medical exemptions keep going up.

In addition to the 0.9% of medical exemptions, another 1.5% of kids, also up as a percentage, are unvaccinated “for other reasons specified under SB 277.”

There are also about 1.7% of kids in kindergarten who enroll as conditional entrants.

Why is that important? Among those conditional entrants are kids with temporary medical exemptions.

And how many kids aren’t vaccinated simply because they are “receiving IEP services?”

So it is not only wrong, it is unethical to try and say that only 0.9% of kids have vaccine exemptions in California this year.

Update on Vaccine Exemption Rates in California’s Clusters

Still, the big story continues to be what’s going on in the clusters of intentionally unvaccinated kids in California and other parts of the United States.

Are they getting vaccinated and protected under SB 277?

Wait, I thought Dr. Bob said that the vaccine exemption rate was just 0.9%. What happened at this Waldorf school? 30% of the kids have medical exemptions!
Wait, I thought Dr. Bob said that the vaccine exemption rate was just 0.9%. What happened at this Waldorf school? 30% of the kids have medical exemptions!

Some actually are!

The MMR rate at the Waldorf school in San Diego was just 44% back in 2014, as a whopping 56% of kids had a personal belief exemption. As sad as it sounds, even though it is still below herd immunity levels of protection, their current MMR vaccination rate of 68% is a big improvement!

Unfortunately, there are many schools with even lower immunization rates. And of course, that means even more students with “medical exemptions” at those schools.

SchoolPMEs
Marin Waldorf School31%
Yuba River Charter64%
Westside Waldorf School37%
Sebastopol Independent Charter45%
Muse Charter50%
Live Oak Charter41%
Nevada City School of Arts31%
Sunridge Charter47%
Santa Cruz Waldorf School34%
Cedar Springs Waldorf School30%
Journey33%
Waldorf School of Orange County33%
Coastal Grove Charter36%
Mariposa School of Global Ed31%
Waldorf School of the Peninsula36%
Maple Village Waldorf School30%

In addition to these permanent medical exemptions (PMEs), some schools also have high rates of temporary medical exemptions.

Medical Exemptions for Vaccines in California are Unusually High

What’s the usual rate of medical exemptions?

As there are few reasons to skip or delay a child’s vaccines, it is lower than those rates.

A lot lower.

In one recent report, Vaccination Coverage for Selected Vaccines, Exemption Rates, and Provisional Enrollment Among Children in Kindergarten — United States, 2016–17 School Year, the median rate of medical exemptions in the U.S. was just 0.2%, with a range of <0.1 to 1.5%.

Also unusual is that in some cases, many of those exemptions are written by just a few doctors. In fact, families often go to these doctors just to get their kids their medical exemptions!

“…the removal of nonmedical exemptions in California was initially effective in increasing vaccination rates, but the substitution between exemption types may render the repeal partially ineffective in improving immunization coverage and preventing VPDs over time.”

Richwine et al on Do Stricter Immunization Laws Improve Coverage? Evidence from the Repeal of Non-medical Exemptions for School Mandated Vaccines

How do we fix this and get more kids vaccinated and protected?

“Beyond fostering compliance, tightening the requirements around medical waivers will also aid in promoting public policies that protect public health.”

Richwine et al on Do Stricter Immunization Laws Improve Coverage? Evidence from the Repeal of Non-medical Exemptions for School Mandated Vaccines

In addition to closing the loopholes that allow some doctors to abuse medical exemptions, it will be important to help parents be more skeptical and see through the anti-vaccine propaganda that other doctors use to scare parents away from vaccinating and protecting their kids.

Vaccines are safe, with few risks, and are obviously necessary.

More on Vaccine Exemption Rates in California

Is Measles Still Eliminated in the United States?

Do you remember when measles was eliminated in the United States?

You probably should.

Remember when we eliminated measles and we used to only have about 100 cases of measles in the United States each year?
Remember when we eliminated measles and we used to only have about 100 cases of measles in the United States each year? Pensacola News Journal July 2000

It wasn’t that long ago…

When Measles Was Eliminated in the United States

After several years of declining numbers of measles outbreaks in the United States, the endemic spread of measles was declared eliminated in March 2000.

“The data indicated that, during 1997–1999, measles incidence has remained low (<0.5 cases per 1,000,000 population) and that most states and 99% of counties reported no measles cases. In addition, measles surveillance was sensitive enough to consistently detect imported cases, isolated cases, and small outbreaks. Evidence of high population immunity included coverage of >90% with the first dose of measles vaccine in children aged 19–35 months since 1996 and 98% coverage among children entering school. In 48 states and the District of Columbia, a second dose of measles vaccine is required for school entry. A national serosurvey indicated that 93% of persons aged >6 years have antibody to measles.”

Measles — United States, 1999

What did that mean?

It is easy to understand when you note that we still had 86 cases of measles in the United States that year.

So, measles wasn’t gone yet. It was just that most cases were imported from outside the country. Only imported strains of the measles virus were causing outbreaks.

“The end of endemic measles transmission in the United States has both domestic and international importance. Domestically, the absence of endemic exposure to measles means few persons in the United States will be infected and risk complications of measles. This decreased risk of exposure provides protection to groups not protected directly by vaccination: children too young for routine vaccination; the few persons who, although vaccinated, are not protected, primarily from failure to mount an adequate response to vaccine; persons for whom vaccine is contraindicated (e.g., those with immunodeficiency); and persons who choose not to be vaccinated.”

Wharton on Measles Elimination in the United States

Unfortunately, the “choose not to be vaccinated” group might be endagering our claim to have eliminated measles.

Is Measles Still Eliminated in the United States?

As we break more and more measles records this year, it would be easy to just say that the endemic spread of measles is no longer eliminated in the United States.

“Endemic measles transmission is the existence of any continuous indigenous chain of transmission of measles virus that persists for >1 year in any defined geographic area (e.g., the United States).”

Orenstein on Defining and Assessing Measles Elimination Goals

Still, when you look at the numbers, technically, measles isn’t yet spreading endemically in the United States.

Although we are seeing measles cases in 27 states, about 70% of them are in just two outbreaks in one state - New York.
Although we are seeing measles cases in 27 states, about 70% of them are in just two outbreaks in one state – New York.

We are getting close though.

The outbreaks in Rockland County and Brooklyn started in September and October 2018. If they aren’t stopped soon, will it be easier to make a case that measles is no longer eliminated in the United States?

“Outbreaks in New York City and Rockland County, New York have continued for nearly 8 months. If these outbreaks continue through summer and fall, the United States may lose its measles elimination status.”

U.S. measles cases in first five months of 2019 surpass total cases per year for past 25 years

It sounds like it.

One thing to consider though, after an unvaccinated visitor introduced measles to Brooklyn from Israel back in October, measles has been reintroduced into the community at least seven other times! This includes travelers from Israel, UK, and Ukraine.

So the outbreak isn’t necessarily a “continuous indigenous chain of transmission of measles virus.”

It is multiple chains in the same community.

“There have been additional cases of measles from international travelers to Rockland, exposing more people to measles.”

2018 – 2019 Measles Outbreak in Rockland County

The same thing has happened in Rockland County after the initial importation from Israel in September.

Measles Elimination Criteria

Does that matter?

It likely should, but let’s also look at how we do with other criteria that are often used to assess the absence of the endemic spread of measles:

  • Few measles cases/low measles incidence – we will have the most cases in 2019 since 1992, but most cases are clustered in just a few big outbreaks
  • The duration of outbreaks is short – outbreaks are getting longer and harder to contain, but part of the problem is the global rise in measles and the reintroduction of measles into existing outbreaks
  • Most cases are associated with international importation – still very true
  • No endemic measles virus strain – outbreaks this year have been associated with strains that are commonly seen in Ukraine, the Philippines, and a few other areas
  • Long periods with no unknown-source cases – most cases are linked to international travel
  • High population immunity – except for pockets of susceptibles, folks who intentionally don’t vaccinate their kids or get themselves vaccinated, we do have high population immunity
  • Low levels of transmission from reported cases – in most outbreaks, that it is still true, unfortunately, there are more outbreaks this year
  • Adequate measles surveillance system – definitely true

What is the best argument that the endemic spread of measles has still been eliminated in the United States?

“A small number of cases have occurred outside of these neighborhoods but have, to date, not resulted in sustained transmission of measles.”

Measles Cases Rise to 466 Including in Two Unvaccinated Children Spending Time in Areas with Measles Activity

Even where there are big outbreaks, measles isn’t spreading outside of very specific communities of intentionally unvaccinated children and adults.

And that’s because most people are vaccinated and protected and aren’t letting measles spread endemically!

Losing Measles Elimination Status

If we did lose our status of having eliminated measles, we wouldn’t be the first.

“As of 30 June 2018, measles transmission in Venezuela has been ongoing for over one year. Therefore, endemic transmission of measles is considered to have been reestablished in Venezuela.”

Fourth ad hoc Meeting of the Technical Advisory Group (TAG) on Vaccine-preventable Diseases

Tragically, since their outbreaks began a few years ago, there have been nearly 10,000 cases and at least 78 deaths. Cases have also spread to many other countries in South America.

Venezuela isn’t the only country where we have seen the return of measles though.

In 2017, the European regional verification commission verified the reestablishment of the endemic spread of measles in the Russian Federation and in Germany.

“Countries in all six WHO regions have adopted goals for measles elimination by 2020.”

Progress Toward Regional Measles Elimination — Worldwide, 2000–2017

Surprisingly, some other countries in Europe, like Belgium, France, and Italy, never eliminated measles.

What’s next?

Hopefully, instead of a new normal, the rise in cases gets us back on track to eliminating and one day eradicating measles.

More on When Measles Was Eliminated in the United States

Who Is ‘Patient Zero’ in the 2019 Measles Outbreaks?

As we climb to ever higher case counts in the 2019 measles outbreaks, you might be wondering who to blame?

Who started the outbreaks?

How Does ‘Patient Zero’ Start a Measles Outbreaks?

As you have likely guessed, there is no one person who started all of this year’s outbreaks. Well, maybe there is. After all, who is responsible for so many folks not getting vaccinated?

In most cases though, we do know who started the outbreak – the “patient zero.”

And it is almost always an unvaccinated traveler, typically a US resident, who got measles abroad and brought it back into the U.S.

What happens next? If they expose a lot of people in an area with low vaccination levels, then you can expect a big outbreak. On the other hand, if most people are vaccinated and protected, you might not see any more cases in that area.

Who Is ‘Patient Zero’ in the 2019 Measles Outbreaks?

So who are these folks?

This year's measles cases are spread out in outbreaks in 26 different states. So there isn't only one patient zero...
This year’s measles cases are spread out in outbreaks in 26 different states. So there isn’t only one patient zero…

They aren’t people who had been recently vaccinated are giving others vaccine strain measles through shedding! That doesn’t happen.

Instead, at least 44 people triggered separate outbreaks after traveling from the Philippines, Ukraine, Israel, Thailand, Vietnam, Germany, Algeria, France, India, Lithuania, Russia, and the United Kingdom.

The 2019 measles outbreaks include the:

  • Rockland Outbreak – an unvaccinated teenager brought measles to Rockland County in September 2018 from Israel.
  • Brooklyn Outbreak – the initial case in Brooklyn was unvaccinated and got measles in October 2018 on a visit to Israel. Measles was reintroduced into the community at least six other times though, four cases were also acquired on visits to Israel, while two people got measles from the U.K., and one from Ukraine.
  • Pacific Northwest Outbreak – a child who had traveled from Ukraine to Washington was the first confirmed case and likely source of the Pacific Northwest measles outbreak.
  • Michigan Outbreak – a traveler from Brooklyn started the Michigan measles outbreak.
  • Northern California Outbreak – a “cluster” of cases in Butte, Tehama, and Shasta counties that was started by a traveler who had recently been to the Philippines.
  • Puget Sound Outbreak – triggered by a Canadian resident who traveled to Seattle, after completing a trip to Japan and New York, where he likely became infected.

Why is it important to find patient zero and know who started an outbreak?

Mostly, it helps you find everyone who was exposed to measles and hopefully limit and quickly control the outbreak.

Make sure you are fully vaccinated and protected, with two doses of MMR, before your next trip so that you're not the next patient zero.
Make sure you are fully vaccinated and protected, with two doses of MMR, before your next trip.

It should also remind everyone that the easiest way to avoid getting measles and avoid triggering an outbreak, is to get vaccinated and protected, especially if you plan on traveling out of the country.

More on Who Is ‘Patient Zero’ in the 2019 Measles Outbreaks?

The Puget Sound Measles Outbreak

Breaking News – there is a new case in King County (see below)

Everyone is likely familiar with the large outbreaks that we have been seeing this year in New York (Brooklyn and Rockland County), Michigan, and the Pacific Northwest.

There have already been 79 cases of measles in Washington so far this year.
There have already been 79 cases of measles in Washington so far this year.

After all, those outbreaks make up the majority of measles cases that have occured so far this year.

The Puget Sound Measles Outbreak

Have you heard of the latest outbreak?

This one, also centered in the Pacific Northwest, began with exposures to a traveler with measles at Seattle-Tacoma International Airport on April 25.

“A Canadian resident from British Columbia who traveled to the Seattle area in late April 2019 has been diagnosed with measles. The traveler, a man in his 40s, has since recovered from his illness.

Prior to arriving in King County, he spent time in Japan and New York during the period that he was infected, two places that currently have measles outbreaks. This case has no connection to the recently-ended measles outbreak based in Clark County, Washington state.

While he was infectious with measles, he spent time in the Seattle area at several locations, including popular tourist attractions and Sea-Tac Airport. Anyone who does not have immunity to measles through vaccination or from previously having measles is at risk for infection if they were at a location of measles exposure.”

Measles case in traveler to King County

Those exposures have led to cases in:

  • King County – 6
  • Pierce County – 2
  • Snohomish County – 1

The latest case is a six-month old infant in King County, with exposures at the Seattle Children’s Hospital Emergency Dept on May 24.

“This case was a household contact of a person diagnosed with measles earlier this month, and was not exposed to measles in the community.”

A new case of measles diagnosed in a King County resident

With exposures in Bothell, Lynnwood, Mill Creek, Orting, Bonney Lake, Puyallup, Renton, Auburn, Issaquah, Woodinville, Kent, and Seattle.

And that’s what has led to the name Puget Sound outbreak. The Puget Sound is an inlet of the Pacific Ocean along the northwest coast of Washington, near Everett, Olympia, Seattle, and Tacoma.

How big will this outbreak get?

Immunization rates in the Puget Sound area are a bit better than in Clark County, where the last Pacific Northwest outbreak was centered.
Immunization rates in the Puget Sound area are a bit better than in Clark County, where the last Pacific Northwest outbreak was centered.

It’s anyone’s guess at this point, keeping in mind that all it would take is for one of these exposures to be in a “pocket of susceptibles” with low immunization rates to start a big outbreak.

And all it would take to stop the outbreaks is for folks to get vaccinated and protected, understanding that vaccines are safe and necessary.

More on the Puget Sound Measles Outbreak