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May 15, 2024
Quarterly Opinion
Nahid Bhadelia
Laura White
Lawrence O. Gostin
Jun 11, 2024
May 1, 2024
Apr 24, 2024
Back to The Milbank Quarterly Opinion
Measles, a highly contagious disease once eliminated in the United States (2000), is making a comeback. This resurgence is fueled by misinformation, lax vaccination laws, and increased religious exemptions. Despite high overall vaccination rates, pockets of low coverage create public health vulnerabilities that could threaten the United States’ elimination status for the disease. We examine here the drivers of recent measles outbreaks and propose a four-pronged approach to strengthen childhood vaccinations.
Measles cases in the United States were on the rise for a decade before the COVID-19 pandemic, culminating in a major outbreak of 1,200 cases in 2019. The pandemic caused a temporary dip due to social distancing measures, but as of April 2024, cases already had surpassed the 2023 total of 58 cases. Globally, measles cases and deaths are also surging after the pandemic, with the largest disruption in measles vaccines delivery in more than three decades.1
Measles is among the most efficiently transmitted infections, with a long incubation period of 10-14 days and pre-symptomatic infectiousness.2 The disease leaves a very small window for contact investigations to curb transmission among undervaccinated communities, despite high overall population vaccination levels, highlighting the importance of early identification of high-risk communities and prevention through vaccinations.
Acute severe complications like pneumonia and encephalitis leading to hospitalization and longer term adverse outcomes have been all but forgotten by the general public. Despite the level of effectiveness of measles vaccines against disease at the individual level (estimated at 93% for 1 dose and 97% for 2 doses, generally providing lifelong protection), it is becoming difficult to maintain population-level immunity as vaccination rates in some areas drop below the required 90–95% coverage.
Measles resurgence is driven not by vaccine failure or viral evolution, but rather social, political, and legislative choices. Vaccine hesitancy increased during the COVID-19 pandemic bolstered by an active network of antivaccination advocacy groups, reported to have gained more than $118 million between 2020 and 2022. While broad support remains for childhood vaccinations, parental concerns about vaccine safety are rising, driven in part by antivaccination sentiment. Last year more parents sought religious and philosophical exemptions for their children from vaccine requirements than ever before.
School entry requirements are associated with increased vaccine coverage and are in place in every state, a policy upheld by the Supreme Court since 1922.3 While Maine (2019), New York (2019), and Connecticut (2021) eliminated all non-medical exemptions in response to measles outbreaks, many states are moving in the opposite direction. Over 80 bills were introduced or enacted during and after the pandemic to weaken vaccination requirements.4 While some apply only to COVID-19 vaccines, others extend broadly, such as a Tennessee law that eliminated all vaccination requirements for home-schooled children. The West Virginia legislature recently passed a law that was vetoed by the governor that would have eliminated vaccine requirements for certain private schools, allowing school administrators to set their own policies.
Courts are also permitting enhanced protection of religious claims against public health requirements. During the pandemic, the Supreme Court struck down public health orders in California and New York that included restrictions on church attendance. One study identified at least 20 cases where courts sided with plaintiffs’ free exercise claims against vaccination requirements.5
A similar trend is occurring in businesses and universities. Following a 2023 Supreme Court decision making it harder to deny claims of religious freedom, the Equal Employment Opportunity Commission challenged employer vaccine mandates that did not accommodate employees’ religious beliefs.
Lastly, some public health officials are contravening well-established guidance. Recently, Florida’s Surgeon General gave parents the choice of whether to isolate unvaccinated exposed children during a measles outbreak at a Broward County school.
Misinformation, legislative restrictions on public health powers, and judicial protection of religious exemptions could lead to more vaccine-preventable disease outbreaks in the future.
Measles outbreaks over the next decade are likely to occur in areas with an overall drop in vaccination rates and where there is already spatial clustering of unvaccinated individuals in the same social networks and communities.
According to the CDC, in 2021-2022, the national kindergarten vaccination rate fell to 93%, from historical levels of 95-97%, with 12 states and the District of Columbia reporting coverage below 90%. Idaho reported the lowest coverage at 81.3%, whereas Hawaii had the largest decline from 94.3% in 2021-2022 to 86.4% in 2022-2023. Ten states failed to achieve 95% or greater MMR coverage due to parental exemption rates at or above 5%.
Lower vaccination rates are also more prevalent in communities with low health care access. In 2019-2020, children who were uninsured, underinsured or Medicaid-covered; living in poverty; or living in rural areas had lower coverage than other children. Racial disparities also exist, pairing challenges of access with vaccine skepticism due to historical distrust and targeting of communities of color by antivaccination advocates.
Finally, reduced global vaccination levels raise risks of measles importation via travel. Global disruption to childhood vaccination could lead to nearly 49,000 additional deaths between 2020 and 2030, 91% of which would be driven by excess measles burden according to a recent modeling study.1
We propose “Four Pillars for Progress in Childhood Immunizations.” First, resources for public health programs to facilitate childhood vaccinations are crucial, but effective programs have been chronically underfunded. Vaccines for Children (VFC) covers vaccine costs for underserved communities. The Public Health Service Act (Section 317) funds immunization programs for children and adults by partnering with health care professionals. The President’s FY 2025 budget proposes to expand the VFC program to all children under age 19 enrolled in CHIP and would cover vaccine administration fees for all VFC-eligible uninsured children, reducing some access barriers.
Second, even as we address mis- and disinformation, the health care system must overcome structural and communication challenges to address vaccine complacency (those deeming infection risks as falsely low) and vaccine convenience (barriers to accessibility). This requires increased well-child visits, a larger and well-trained vaccination workforce, reduced administrative burdens, and increased vaccine-related reimbursement. Public health agencies must support stakeholders such as community leaders, schools, and public clinics to reach both vaccine hesitant and willing families. CDC’s Routine Immunizations on Schedule for Everyone (Let’s RISE) campaign supports sharing accurate information and effective messaging and strategies with these stakeholders to increase vaccination.
Third, we need more granular data about vaccination rates to enhance surveillance and targeted outreach to communities at risk and their clinicians. Clustering of unvaccinated children even at the level of blocks, neighborhoods, or quadrants corresponds to a higher cumulative measles incidence.6 Yet, vaccination data are currently aggregated at the county or state level. Improved collection, coordination and sharing of school- or clinic-level data would provide a more accurate assessment of outbreak risk and enable predictive intelligence.
Lastly, the COVID-19 pandemic appears to have increased vaccine skepticism among policymakers. Real-time national databases highlighting proposed and passed legislation, as well as judicial challenges to childhood vaccination, across all states would improve the ability of public advocates to perform outreach to affected communities more effectively. Constructive dialogue with communities and political leaders could make the informational environment more conducive to vaccine uptake.
The next decade will be a critical window to prevent measles from regaining a foothold. This is a call to action for policymakers, health professionals, and communities to work together. The resurgence of measles provides a stark reminder that even well-established progress in public health can be quickly undone.
Dr. Nahid Bhadelia is the founding director of BU Center on Emerging Infectious Diseases. She is a board-certified infectious diseases physician and an Associate Professor at the BU School of Medicine. Dr. Bhadelia’s research focuses on operational global health security and pandemic preparedness, including medical countermeasure evaluation and clinical care for emerging infections, diagnostics evaluation and positioning, infection control policy development, and healthcare worker training. She served as the Senior Policy Advisor for Global COVID-19 Response for the White House COVID-19 Response Team in 2022-2023 and the interim Testing Coordinator for the White House MPOX Response Team.
Dr. Laura White is a Professor of Biostatistics at the Boston University School of Public Health. She co-directs the Data Science and Surveillance Core of the Center on Emerging Infectious Diseases and Associate Director of the Population Health Data Science Program at Boston University. Her research focuses on developing better statistical and modeling tools to understand infectious disease transmission and burden.
Lawrence O. Gostin is University Professor in Global Health Law at Georgetown University, faculty director of the O’Neill Institute for National and Global Health Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He has chaired numerous National Academy of Sciences committees, proposed a Framework Convention on Global Health endorsed by the United Nations Secretary General, served on the WHO Director’s Ad Hoc Advisory Committee on Reforming the WHO, drafted a Model Public Health Law for the WHO and the Centers for Disease Control and Prevention, and directed the National Council of Civil Liberties and the National Association for Mental Health in the United Kingdom, where he wrote the Mental Health Act and brought landmark cases before the European Court of Human Rights. In the United Kingdom, he was awarded the Rosemary Delbridge Prize for the person “who has most influenced Parliament and government to act for the welfare of society.”
