California’s Tightened Rules Pay Off Against Measles

May 14, 2019by Soumya Karlamangla and Priya Krishnakumar

LOS ANGELES — Four years ago, a public health nightmare unfolded in California: A person with measles visited Disneyland during the holiday season, likely exposing thousands to the highly contagious disease. Over the next few weeks, more than 145 people across several states and three countries were diagnosed with measles.

In response, California declared war on the disease. Legislators barred parents from opting out of vaccines due to their personal beliefs. The state cracked down on schools with low immunization rates and even took on one of the doctors most popular among anti-vaccine parents in California.

This year, as other parts of the country struggle with measles outbreaks, California is much more protected. Though more than 750 people have been diagnosed with measles in the United States this year, only 42 of those cases, or less than 6%, are in the state, which is home to about 12% of the U.S. population.

To some, California is now a model for the rest of the nation in how to tackle the disease in an era of vaccine misinformation fueled by social media that has posed a major challenge to maintaining public health.

“If the entire continental U.S. instituted California’s current law, I think the U.S. would have a very low risk of measles outbreaks,” said Matthew Woodruff, a postdoctoral fellow and immunologist at Emory University’s Vaccine Research Center, “You’re still going to get enclave communities that are going to be at risk, but I think that the fear of (measles) spreading city to city, like it’s doing now, would be cut drastically. … California did the right thing.”

This year’s outbreak has been a wake-up call for some communities that have watched with alarm as the disease spread. California’s experience during the Disneyland outbreak was much the same, exposing how the state’s vaccination rates had fallen as a growing number of parents chose not to immunize their children out of fear of the shots’ side effects.

Though California’s law applies to all schoolchildren, it in effect targeted mostly affluent parents who were choosing to opt out of the law because of their personal beliefs, “using their resources to fend off vaccination,” Woodruff said.

Those communities are still finding loopholes, experts say. But three years after the law took effect, there is evidence that making vaccines compulsory works.

Sen. Richard Pan, D-Sacramento, who wrote the state’s strict vaccination law, said Californians are still at risk of catching measles when they travel, or from people visiting from other states. “The good news is that thanks to what we’ve done so far, it seems like none of these individual instances have really taken hold in a way where they have blossomed into an outbreak,” Pan said.

In 2000, measles was declared eliminated in the United States. At the time, enough Americans were vaccinated against the disease that officials believed it would be very difficult for it to spread here.

But then vaccination rates began to drop as fears of side effects took root, especially in California. One of the most contagious diseases in the world, measles is the first to come back when vaccine coverage falls, experts say. Whereas someone with the Ebola virus is likely to infect two other people, one person with measles can be expected to infect 12 to 18. The only way to prevent an outbreak, scientists say, is to rely on what is called herd immunity.

If enough of the population is vaccinated, a single case of measles won’t be able to spread in a community. High vaccination rates protect unvaccinated people too, including babies who are too young to get the measles shot, people who can’t get the vaccine for medical reasons and others for whom the vaccine doesn’t work. Doctors say roughly 95% of a community needs to be vaccinated to achieve herd immunity for measles. In late 2014, when measles began to spread at Disneyland, California’s rate had fallen below that.

The state’s measles immunization rate among kindergartners reached a low of 92.3% in 2013, fueled by parents opting out of vaccines for their children.

So legislators decided to address that. Despite major pushback from some parents, the state passed SB 277, a law that banned parents from citing personal beliefs as reason not to vaccinate their children.

Now parents must have a medical excuse signed by a doctor to get out of vaccines. California, Mississippi and West Virginia are the only three states with such a law.

In the 2017-18 school year, California’s measles, mumps and rubella vaccination rate reached 96.9%, according to state data.

Though the law applies only to schoolchildren, its effects have likely been more widespread, Pan said.

“The discussion in the public sphere that took place around SB 277, and then the public health campaign that resulted … has overall helped increase awareness and increase vaccination rates,” he said.

Still, California’s law hasn’t been a silver bullet.

Though parents are unable to secure personal-belief exemptions, many have turned to medical exemptions to excuse their kids from their required shots.

In some schools in California, more than 50% of kindergartners still don’t have all of their required shots. Half of California’s 58 counties have vaccination rates below the 95% threshold required for herd immunity.

Just because the overall state measles vaccination rate is high, that doesn’t mean that schools with low vaccination rates aren’t at risk, experts say. “If it hits one of those pockets, then the outbreak can pick up steam,” Pan said.

It seems that some parents have found doctors who will write them suspect medical exemptions from vaccines. Physicians have been accused of writing exemptions because a child has asthma or psoriasis. Though vaccination rates have gone up, so too have medical exemption rates.

“I think people are shopping around a little bit for physicians, and they’re finding them,” Woodruff said.

California legislators are weighing a bill that would force the state to track each medical exemption, in an attempt to tamp down on fraudulent ones.

Since the 2015 vaccination law was passed, only one California physician has been sanctioned for fraudulently writing medical exemptions. Orange County-based pediatrician Dr. Bob Sears was put on probation last year for excusing a 2-year-old from all vaccines.

The new bill, also written by Pan, would give the state health department final say over whether a child should receive a medical exemption from some or all vaccines required to attend public or private school. Currently doctors can excuse a child from vaccines for any reason they deem appropriate.

In West Virginia, each medical exemption must be vetted by the public health department. That state’s medical exemption rate is half of California’s.

“The so-called physician who, for money, will write these bogus exemptions — that’s terrible, but nevertheless, we have an overall (vaccination) rate higher than most of the country,” said Dr. James Cherry, a UCLA expert on infectious diseases.


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