Global measles cases are on the rise, in spite of the widespread availability of a life-saving vaccine. It’s an ominous reflection of waning vaccine confidence, experts say.
In the United States, multiple children from Broward County were sick with the disease this month, school officials in Florida confirmed. However, the state’s Surgeon General Joseph Ladapo continued to make statements that could appear to diminish, if not discredit, the use of vaccines. In a Feb. 20 letter to school officials, Ladapo wrote that Florida’s Department of Health “is deferring to parents or guardians to make decisions about school attendance,” citing the “high immunity rate in the community” and “the burden on families and the educational costs of healthy children missing school.”
Critics say high-profile statements like Ladapo’s make it easier for people to feel validated in not getting their kids vaccinated against measles. Epidemiologist Katelyn Jetelina called the surgeon general’s message “unprecedented” on X, the platform formerly known as Twitter.
“Unvaccinated kids need to stay home for 21 days during an outbreak” to avoid the “very real chance of infection, hospitalization, death or serious damage to the immune system,” Jetelina wrote.
Vaccine exemption rates above 5 percent limit the level of achievable vaccination coverage, which increases the risk for future outbreaks of preventable diseases. Chart by Megan McGrew/PBS NewsHour
Weeks earlier, on Jan. 25, the Centers for Disease Control and Prevention alerted clinicians to be on the lookout for measles after 23 cases were counted across the nation, including seven tied to international travel and two separate outbreaks made up of more than five patients. Most cases were identified in children and adolescents who had not been vaccinated against measles, the alert said.
Experts “are seeing measles everywhere,” said Dr. Natasha Crowcroft, the World Health Organization’s senior technical adviser on measles and rubella. “We’ve got a perfect storm coming this year.”
“We’re not just seeing cases, we’re seeing transmission, which means vaccine levels aren’t what we’d like them to be,” said Saskia Popescu, an assistant professor of epidemiology and public health at the University of Maryland School of Medicine.
Measles is a highly contagious viral infection, spread through contact with mucus that has been coughed or sneezed, or through breathing the same air as an infected person hours after they have left a room. In 2000, U.S. health officials had declared the end of the disease’s endemic spread, eliminated by decades of vaccination campaigns. In the years since, the measles vaccine has saved an estimated 57 million lives worldwide, according to the CDC.
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But now, data show a dangerous decline in vaccination among schoolchildren, both in the U.S. and in Europe.
“That is a huge wakeup call,” said Dr. Syra Madad, an epidemiologist, senior director at New York City Health + Hospitals and fellow at the Harvard Kennedy School’s Belfer Center for Science and International Affairs. She said when it comes to vaccination rates, each percentage point “can translate into thousands of children.”
So far, Europe has seen a far more dramatic rise of the disease – cases grew nearly 45-fold in 2023 compared to a year earlier, according to WHO. In late January, British health officials urged parents to get their children vaccinated against measles after hundreds of cases were confirmed.
Public health experts say 95 percent or more of children should be vaccinated against the disease to foster sufficient herd immunity within a community, protecting people with weakened immune systems, such as cancer patients and babies. According to data from the United Kingdom’s National Health Service, 85 percent of children there have received both doses by age 5, giving the disease an opening.
Experts point in part to the negative effects of COVID-era misinformation about the safety and efficacy of vaccines. But when it comes to measles, there’s actually a longer history that helped set the stage for the broader decline in vaccination confidence.
Why measles made a comeback
Researchers developed the measles vaccine in 1963, and U.S. children have received this scheduled vaccine before they start school ever since. According to a report from the CDC, 93 percent of kindergartners for the 2022-2023 school year got their two doses to prevent measles, mumps and rubella – a combination that has been safe, effective and available since 1971.
However, misinformation has chipped away at hard-won gains. In 1998, Andrew Wakefield published a study in the journal Lancet that claimed a thoroughly debunked connection between the measles-mumps-rubella vaccine and autism. The study ignited a media firestorm, despite being founded on misleading research and unethical practices, and fueled celebrity-fronted, anti-vaccine campaigns.
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His fraudulent claims led Wakefield to lose his medical license in the U.K., but the damage endures. Two decades later, measles gained a foothold in pockets of the U.S., including parts of southern California and New York City, leading to one of the largest measles outbreaks in recent history with nearly 1,300 cases confirmed in 2019. According to the CDC, a majority of cases were among those who were unvaccinated against the virus.
Chart by Megan McGrew/PBS NewsHour
Now, experts say, the climate for misinformation is even worse.
During and even before the COVID pandemic, the public health community was overwhelmed by crisis, budget cuts and staffing shortages, and it initially dismissed the threat of anti-vaccine attitudes, said Heidi Larson, who directs the Vaccine Confidence Project. Those factors meant they fell behind in the fight against the technology being used to spread misinformation and disinformation.
False claims were fanned by people who genuinely believed vaccines were unsafe, but also by people with financial or political motives for using fear to control people’s behavior, she noted. With the COVID vaccines developed and deployed faster than ever before, the people who protested their use found a “a huge stage with any vaccine grievance anyone had,” Larson said.
Misinformation about the new virus shaped people’s perceptions of the need to get vaccinated against other diseases, like measles, Larson said, and may leave more long-lasting effects on public health.
In addition to stirring a new falsehood fever pitch, the COVID pandemic disrupted general health services. People avoided sitting in waiting rooms or exam rooms in health care facilities, delaying preventative care. Childhood vaccination rates fell around the world. According to the CDC, the pandemic erased years of progress toward greater global vaccine protection against measles, with an increase in cases and deaths, particularly among children.
Today, some states face a greater threat of outbreaks than others. For example, during the 2022-2023 school year in Idaho, 84 percent of kindergartners were vaccinated against measles, compared to Mississippi, where 98 percent of kindergartners had received both doses.
How to move forward
All U.S. states require certain vaccines for schoolchildren, but some have adopted or expanded exemptions to go beyond medical concerns to include religious and philosophical beliefs, according to the National Conference on State Legislatures.
Since 1979, Mississippi had vaccinated nearly all schoolchildren against measles. That state, one of the poorest in the nation with some of the worst health outcomes, earned praise for its efforts to slow the spread of preventable illness. In July, Mississippi began for the first time to offer religious exemptions for routine childhood vaccinations, which followed a ruling from U.S. District Judge Sul Ozerden that it had to offer exemptions like most other states.
Through these exemptions, Madad said more parents are opting their children out of vaccinations, influenced by misinformation. She expects use of these exemptions to expand because “because this is not just a public health issue, it’s also a political issue.”
Such exemptions have further hobbled outreach efforts by public health departments that have struggled for years due to other strains. Dr. Jesse Ehrenfeld, president of the American Medical Association that has opposed religious-based vaccine exemptions, echoed that these dispensations are informed by misinformation, which “continues to drive vaccine hesitancy.”
To prevent more measles outbreaks, Ehrenfeld said the U.S. must improve vaccine coverage and strategies to combat these untruths. While lawmakers have considered regulations to reduce the spread of harmful messages, focusing on regulation alone is not the answer, Larson believes. The people and groups who generate them have “become incredibly sophisticated,” she said, jumping to platforms with less regulation or going offline altogether, showing up at town halls, playgrounds and on billboards. The misinformation ecosystem only gets more complicated with the introduction of text generators and deepfakes powered by artificial intelligence.
One solution seems deceptively simple and low-tech: For patients with questions about what to do about vaccination, Ehrenfeld urged them to ask their doctor.
Health officials and public leaders must pay “attention to trust building,” Larson said. “People turn to this stuff when they feel they’re not getting the answers to their questions.”
To bring people back to official sources of public health information, Larson added, “there needs to be a much bigger investment from public health institutions to be there, where people are. If they don’t,” she warned, “the gap between official information and where people are going is going to get bigger and bigger.”
That will also require health care providers, many of whom have reported record-high burnout, to listen to patients and “to come from a place of empathy,” Popescu said. She also said health workers need training in how to respond effectively when a patient seems influenced by misinformation.
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Madad has faced this challenge in her personal life. During the 2018-2019 measles outbreak that spread to hundreds of children, Madad said a friend of hers had not vaccinated their children against measles because they believed the disease “is not around.”
After listening to their logic for avoiding vaccination, Madad told her friend that the vaccine is 97-percent effective and very safe. But in that instance, she realized those statistics were less helpful than telling the person how the vaccine would benefit them.
She then described what life was like before the measles vaccine existed. She described how an estimated 500,000 children were sick in the U.S. and how hundreds died each year. She showed them photos of measles patients.
“Because they don’t see it and because of how well vaccines have worked, they have forgotten what humanity has gone through,” Madad said. “Do you want to put your child through something like that?”
